Summary of Benefits and Coverage (SBC)

The healthcare industry has been shrouded in mystery for years. In fact, prior to the Affordable Care Act passing, it was hard for policy members to know exactly what their health insurance plans covered. In an effort to create a more transparent healthcare industry, the Summary of Benefits Coverage was born and accompanies all health insurance plans and policies. 

What Are Your Summary Of Benefits And Coverage (SBC)?

Your Summary of Benefits and Coverage refers to an easy to understand outline provided by your health insurer that details what health benefits you are entitled to through your policy. Summary of Benefits and Coverage are part of an effort to create more transparency in the healthcare industry and are required to be written in short, easy to understand language, and include a uniform glossary of medical care terms. Additionally, your Summary of Benefits and Coverage will include detailed examples of your coverage, that include 2 common, real-world medical situations.

Where Can You Find Your Summary Of Benefits?

Typically, finding a health plans SBC is easy. If you are searching for health insurance through the marketplace, you will find a link to the Summary of Benefits and Coverage on each plan's page. If you are enrolling in a private health insurance plan outside of the marketplace, then you can usually find the Summary of Benefits and Coverage when previewing their plans, or simply by asking for a copy from the health insurer.

It is a lawful requirement for health insurance companies to provide an SBC to their members or potential members. If you find that the Summary of Benefits and Coverage is too difficult to understand, you can as for a uniform glossary as well, or use First Quote Health's glossary to review terms you are unfamiliar with. 

When And Why SBC Was Implemented

Summary of Benefits and Coverage became a requirement under President Obama when he and his administration passed the Affordable Care Act. The purpose of the SBC is to create more transparency in the healthcare industry by providing individuals and families standard information when shopping for health coverage. The Summary of Benefits and Coverage help people make informed decisions about the plan they are about to enroll in, making it easier to shop for health insurance.

Summary Of Benefits And Coverage Example

Say you just turned 26 years old and just got kicked off of your family health insurance plan. Being new to health insurance, you search for a plan through the marketplace and choose a Bronze Plan because it offers the lowest monthly premium payments. Aside from paying each month to stay covered, you really don't know what else your plan covers, and what other costs you may be responsible for. Then, you receive your Summary of Benefits and Coverage that looks something like this.

After reviewing your SBC, you see that before your benefits kick in, you will have to pay what is known as a deductible. You've heard this term before, but never knew what it meant. Luckily, right next to the term is a definition, and on the next page is a real-world example that outlines how your deductible works. While you may not be an expert on all things health insurance, you know have the tools and resources to navigate your health benefits.

A few months into your policy, you see a skin rash appear. Now, you usually go to your primary care physician, but it takes about two weeks to schedule an appointment. You know that your doctor is just going to refer you to a specialist, but you'd rather not wait. You review your SBC and see whether or not you need a referral to see a dermatologist, and discover you don't. Now, you can skip a step, schedule an appointment with an in-network specialist, and get your rash taken care of. Even better, you know exactly how much it will cost you.

Summary Of Benefits And Coverage Distribution Requirements

There are regulations that you should be aware of when it comes to Summary of Benefits and Coverage distribution requirements. Here are the times when the SBC must be provided to members, or prospective members of a health plan.

• Previewing Marketplace Plans - You should be seeing the Summary of Benefits and Coverage for each plan you preview through the marketplace. The whole purpose of the SBC is to make it easier for individuals and families to compare and shop for health coverage.
• Application or Enrollment - The SBC must be provided to an individual or family by the first day they are eligible to enroll in the plan.
• Special Enrollment - If you are eligible for a Special Enrollment Period (SEP), then you should receive your Summary of Benefits and Coverage no later than 90 days after enrolling in your plan.
• Plan Renewal - If you are eligible to renew your health insurance plan, or will be eligible for renewal, your insurer has to provide you with the SBC no later than 30 days prior to your renewal date. 
• When You Request It - Your health insurance provider has to provide you with your SBC within 7 business days after the request is made.