A summary of Benefits and Coverage document, or SBC, helps to clarify the

cost-sharing structure of a plan using easier-to-understand terms. The SBC

also makes it easier to compare plans during open enrollment.

*Note: These example images do not depict your specific coverage.

Header:

At the top of each SBC is a header that gives the insurer’s name, the official plan name, the coverage period, the election tier, and the plan type. The election tier will describe who is covered under the plan. The plan type will indicate what sort of provider network you will have available to you under the policy.

Important Questions:

This section is where you look to get a sense of the plan’s structure, including deductibles, covered services available before you meet the deductible, what types of providers are covered, and the plan’s out-of-pocket maximum. Unless you have specific medical needs in mind, this will probably be the most important section of the SBC to examine when comparing plans.

Common Medical Events:

This table shows the cost of specific services grouped into common medical needs, such as office visits and tests. If your plan has a provider network, this table will also tell you how much it costs to see a provider outside of the network. Pay attention to the limitations column, as these exceptions are often substantial.

Review the top ribbon of the Common Medical Events section to confirm the cost-sharing structure. When reviewing services, look for categories that say, “deductible does not apply.” With these services, your insurer shares the cost right away. For most services, the “what you will pay” column describes the cost-sharing after the deductible has been met.

Excluded Services and Other Covered Services:

This section shows excluded services that your plan generally does not cover and other covered services that don’t fit into the “Common Medical Events” section. Be careful if this section crosses a page break in the SBC - it can be easy to mistake excluded services for covered services.

Coverage Examples:
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To help make the structure of the plan easier to digest, each SBC provides a few

example scenarios of how a procedure or treatment would be covered by the plan,

such as pregnancy, diabetes treatment, or a simple fracture. These scenarios help you see how different aspects of the plan fit together. They also show you how to think about generating an estimate of your own expenses, especially if you are new to the details of health insurance. Remember that your expenses will probably be different than the examples.