How to read a Summary of Benefits and Coverage

Every health plan is required to give you a Summary of Benefits and Coverage, usually called the SBC. It follows a standard format, so you can put plans from different insurers next to each other and compare them on the same terms. It is one of the most useful documents in the enrollment process, and one of the most often skipped.

Where to find it

You can typically find the SBC linked from each plan's listing on HealthCare.gov or your state's marketplace, on the insurer's website, or in the materials an employer provides during enrollment. It is free, and you are entitled to see it before you enroll.

The opening questions section

The SBC opens with a table of important questions and the plan's answers. This is the quickest way to understand how the plan is built. It typically covers:

• The overall deductible, which is how much you pay for covered care before the plan starts to share costs.
• Services covered before you meet the deductible, which often include preventive care.
• The out-of-pocket limit, the most you would pay for covered, in-network care in a year.
• What is not counted toward the out-of-pocket limit, such as premiums and care the plan does not cover.
• Whether the plan uses a network, and whether you pay more for out-of-network providers.
• Whether you need a referral to see a specialist.

Terms worth knowing

Certain terms appear throughout the document. A copayment is a fixed amount you pay for a service, such as a visit. Coinsurance is your share of the cost expressed as a portion of the allowed amount, which you typically pay after meeting the deductible. The allowed amount is the price the plan has agreed to pay for a service. A standard glossary of these terms is available alongside the SBC, and it uses the same definitions across insurers.

The common medical events table

The longest part of the SBC is a table organised by situations people often run into, such as visiting a doctor, having a test, needing a prescription, going to the emergency room, or having a baby. For each, it shows what you would pay with an in-network provider and with an out-of-network provider, plus any limitations or exceptions.

The limitations column deserves close reading. It is where you may find notes on prior authorization, visit limits, or services that cost more if you do not get approval first.

Excluded and other covered services

Near the end, the SBC lists services the plan generally does not cover, and some it does cover that you might not expect. Adult dental care, long-term care and cosmetic surgery are common examples of exclusions, though every plan differs. If a service matters to you, check this section and then confirm in the full plan documents.

Coverage examples

The final pages show coverage examples: illustrations of what a person might pay under the plan for a sample situation, such as having a baby or managing a long-term condition. They are useful for comparing how plans handle the same situation.

Coverage examples are not cost estimates. Your own costs depend on the care you receive, the prices your providers charge and the plan's rules.

What the SBC does not tell you

The SBC is a summary. The full plan document, sometimes called the evidence of coverage or policy, is what governs. The SBC also does not list which doctors are in the network or exactly which drugs are covered. For those, you need:

• The plan's provider directory, to check your doctors, hospitals and pharmacy.
• The plan's formulary, or drug list, to check your prescriptions and their tiers.
• The full plan document, for the detailed rules on any service you expect to use.

Reading it well

Start with the care you used last year and expect to use this year. Find those services in the common medical events table and note what each plan would charge. Then check the deductible and out-of-pocket limit to see your exposure if something unexpected happens. A plan with a lower premium can cost more overall if you use a lot of care, and the reverse can also be true.

The SBC is designed to be read by ordinary people, not specialists. A careful half hour with it, alongside the network and drug list, is often the difference between a plan that looks right and a plan that is right.

This guide is general education about how coverage typically works. It is not legal, tax, financial or medical advice. Plan rules, dates and availability vary by state and change each year.