Not sure how to make sense of your Summary of Benefits and Coverage (SBC)? You’re not alone. The SBC is a short, easy-to-read document that explains what your health insurance plan covers. Think of it as a simplified version of your policy—without all the confusing legal terms. It helps you understand what you’ll pay for medical care and makes it easier to compare plans during open enrollment.
Under the Affordable Care Act, all insurance providers must give you an SBC for each plan they offer. You can usually get it from your employer’s HR department, or directly from your insurance company.
Tips for Reading Your SBC
Even though SBCs are meant to be user-friendly, they can still be a bit tricky. Here’s a quick guide to help you understand what to look for:
1. Header
At the top, you’ll see basic info like:
- The insurance company and plan name
- The dates the plan covers (this might not be January to December!)
- Who the plan covers (just you, or your whole family?)
- The type of plan (like HMO or PPO)
👉 Double-check that the plan details match what you signed up for.
2. Important Questions
This section gives you an overview of:
- How the plan works
- Your deductible
- What you’ll pay before and after meeting your deductible
- Which doctors or providers are included
📌 Tip: This is the best spot to compare plans quickly, especially if you don’t have specific medical needs in mind.
3. Common Medical Events
This part breaks down the costs of everyday care—like doctor visits, tests, or hospital stays. It shows what you’ll pay in-network vs. out-of-network, and any special rules you need to know.
💡 Be sure to check the “limitations” column—it points out important exceptions. For instance, your doctor might be in-network, but their lab could be out-of-network.
4. Easily Missed Details
At the top of the “Common Medical Events” section, look closely at the cost-sharing details. Sometimes, you’ll only start paying after meeting your deductible. But in other cases, you’ll share the costs right away (look for the phrase “deductible does not apply”).
Also, check for a clarification page—it can explain some of the tricky terms.
Also Read: Do I Qualify for a Special Enrollment Period?
5. Excluded & Other Covered Services
This part tells you:
- What services are not covered
- Extra covered services that don’t fit into the common categories
⚠️ If this section continues onto the next page, be careful! It’s easy to confuse what’s covered with what’s not.
6. Consumer Protection Info
This section covers your rights and how to file complaints if you run into problems with your plan. It includes:
- How to keep your coverage
- How to appeal decisions
- Info on essential coverage standards
- Language and accessibility support
You might not need this info right away, but it’s good to know where to find it.
7. Coverage Examples
Each SBC includes real-world examples—like how the plan would cover pregnancy or diabetes treatment. These give you a better sense of how costs add up and what you might pay.
🔍 Note: These are just samples—your actual costs may vary.
💬 Tip: Some companies offer tools (like MyHealthMath) to give you personalized estimates based on your expected medical needs.
Also Read: What are the Top Health Insurance Options in Texas?
A Few Final Tips:
Plan Year vs. Calendar Year:
Your plan year might not start in January. What matters most is that your deductible resets at the start of your plan year—not the calendar year. This also affects how HSA and FSA contributions work (they follow the calendar year).
Need more help?
Your insurance company should provide a glossary of terms. Underlined words in your SBC are explained there. For a general idea, you can also check out the Department of Labor’s example glossary online.
Want More Help During Open Enrollment?
Download our Open Enrollment Employee Resource Guide—it’s full of easy-to-follow tips to help you make the best insurance choices for you and your family.
