Summary of benefits and coverage

The SBC is the side-by-side tool for health plans. Every insurer and group health plan uses the same format, so you can line up two plans and compare the deductible, copay amounts, coinsurance, out-of-pocket limits, network rules and exclusions in the same places. The model form says the SBC shows how you and the plan would share the cost of covered services, and also says "This is only a summary," according to the CMS SBC template (opens in a new tab). Confirm the premium, the full list of exclusions and your provider network separately.

How to read the cost numbers, with an example

The CMS completed sample SBC (opens in a new tab), for a 2017 sample plan, lists a $500 individual deductible, a $2,500 individual in-network out-of-pocket limit and 20% coinsurance. The table applies that coinsurance to one in-network service after the deductible is met.

If the deductible had not been met, you may owe the allowed amount first, subject to the plan's terms. Premiums, excluded services, balance-billed amounts and other charges outside the SBC's cost-sharing rules can be added on top. These figures describe a sample plan, not a current or standard benefit level.

The figures that change what you pay

Each line on an SBC moves your share of the bill in a different way. The values below come from the CMS sample and vary by plan.

• Deductible. What you pay before the plan begins paying for many covered services; the sample lists $500 individual or $1,000 family.
• Copayment. A fixed amount for a covered service, varying by service and plan.
• Coinsurance. A percentage of the allowed amount you pay after the deductible; the sample uses 20%.
• Out-of-pocket limit. The yearly cap on specified covered cost sharing. The sample lists $2,500 individual or $5,000 family in network, and $4,000 individual or $8,000 family out of network. The out-of-pocket maximum entry explains what counts toward it.
• Network tier. In-network care generally costs less; out-of-network care can bring higher cost sharing and balance billing.
• Referral rules. Some plans require a referral before you see a specialist.
• Premium. Premium information is provided separately from the SBC. A plan with a higher deductible may carry a different premium, but the SBC does not show that trade-off.

The deductible is not your maximum yearly cost. Coinsurance, copayments, premiums, noncovered services and balance-billed charges can keep adding up until the out-of-pocket limit is reached, if those charges count toward it at all.

Where you will get an SBC

A group health plan and a health insurer offering group or individual coverage must provide an SBC for each benefit package, without charge, under 45 CFR § 147.200 (opens in a new tab). The form must use a uniform format and understandable terms and generally may not exceed four double-sided pages. You will usually see it with application materials, before enrollment, at renewal or re-enrollment, after certain changes and within seven business days after you ask for one. It often sits beside a quote, an employer enrollment packet, a renewal notice or a Marketplace plan-selection screen.

It is not the declarations page, insuring agreement, exclusions, endorsements or a claim letter. Auto, homeowners, renters, life, pet and business policies may use labels such as "benefits summary," "coverage summary" or "outline of coverage," and those do not automatically mean the federal SBC. Medicare Advantage benefit packages are excluded from the federal SBC requirement.

An employer plan also has a Summary Plan Description, an ERISA document explaining eligibility, participation, claims procedures, appeals and plan administration, according to the U.S. Department of Labor (opens in a new tab). The SPD and the plan documents carry details the shorter SBC does not.

Questions to ask an agent or insurer

1. Which SBC applies to my exact plan, coverage period, family tier and network option? The values differ by plan, tier, network and year.
2. What are my deductible, copayments, coinsurance and in-network and out-of-network out-of-pocket limits? These figures decide how covered costs are divided.
3. Are my doctors, hospitals, labs and prescriptions in the preferred network or formulary level? Network and drug-tier differences can change what you pay.
4. Which services are excluded, need authorization, are limited or are covered before the deductible? The full policy or plan document holds the complete limits and exceptions.
5. What is the premium, and will a renewal or plan change alter these figures? The premium is separate, and a renewal can come with a new SBC.

Frequently asked questions

Short answers to common questions about the SBC.

Is an SBC the same as my policy?

No. It is a summary, and the complete policy, certificate, Summary Plan Description, evidence of coverage and applicable law set the governing terms. A claim can be limited by exclusions, definitions, medical-necessity rules or authorization requirements that the SBC does not show in full.

Does an SBC guarantee what a claim will pay?

No. Its coverage examples are standardized illustrations, not personal quotes. Actual payment depends on the treatment, allowed amount, network status, exclusions, authorization rules and policy terms, according to HealthCare.gov (opens in a new tab).

What is an SBC called in Spanish?

The official Spanish form is the "Resumen de beneficios y cobertura," and it explains how you and the plan would share the cost of covered services, according to the CMS Spanish SBC template (opens in a new tab). Ask your insurer or plan whether a Spanish copy of your plan's SBC is available.