Summary of Benefits & Coverage (SBC) – How to read it, what to look for?
All health plan companies are required to provide an SBC for each of their different plans. When you’re making decisions about buying a plan or using your benefits, an SBC can be a useful tool to help you compare costs and understand coverage options.
Here’s a step-by-step look at what information is in an SBC:
- An overview of what’s covered
- An explanation of what’s not covered and/or the limits on coverage
- Information on costs you might have to pay — like deductibles, coinsurance and copayments
- Coverage examples, including how coverage works in the case of a pregnancy or a minor injury
- A reminder that the SBC is only a summary. To get all the details, you’ll want to look at complete health plan documents.
- Information about where to go online to review and print copies of complete health plan documents
- Where to find a list of network providers
- Where to find prescription drug coverage information
- Where to find a Glossary of Health Coverage and Medical Terms (also called a “Uniform Glossary”)
- A contact number to call with questions
- A statement on whether the plan meets minimum essential coverage (MEC) for the Affordable Care Act (ACA)
- A statement that it meets minimum value (plan covers at least 60 percent of medical costs of benefits for a population on average)
What is an Explanation of Benefits (EOB) and how to read it?
An Explanation of Benefits (EOB) statement summarizes the costs of your healthcare services and how your health insurance plan processes the claim. It’s not a bill but a statement of how your plan applied coverage.
Tips for reading your EOB:
- Review the claim details to ensure the services and dates are accurate.
- Check the amount paid by your insurance and compare it to the total amount charged.
- Understand how your deductible, coinsurance, and copays are applied.
- If you have questions about your EOB, contact your insurance provider or your doctor’s office.
What is an Evidence of Coverage (EOC) and why is it important?
An EOC (also known as a “Certificate of Coverage”) is a document that can answer many questions about a Medicare Advantage plan or a Part D prescription drug plan. It gives you important, in-depth details about what the plan covers and how much they pay. It provides the information you need to find out if the tests, procedures, and medication your doctors advise are covered by your plan, as well as how to file an appeal. If you have Traditional Medicare (Parts A and B) you won’t get an EOC because it and your Medigap plans are standardized. For these plans, refer to the Medicare and You handbook available at Medicare.gov.