Reading your Summary of Benefits and Coverage!

Published by Your Health Idaho on

In case you’ve already filed away your Summary of Benefits and Coverage (SBC) or it’s sitting at the bottom of a “To be read later,” pile, here’s a quick explanation of what’s in it and why it’s important to you. Every health insurance plan purchased through Your Health Idaho provides consumers with an SBC. So you should have yours from your insurance carrier. The great thing about SBCs is that they give you an outline of what’s covered in your plan so you don’t have to do a deep dive into the lengthy legal version.

First, SBCs for all plans purchased through Your Health Idaho are required to be uniform. Not only can they be used to compare apples-to-apples when you’re shopping for a plan, but even if you change plans, your new SBC will still be easy to read because it’ll have the same format as the one from your last insurance provider.

At the top of each SBC you’ll find the name of the insurance provider, the name of your plan and the plan’s coverage period. Then you’ll see what type of plan you have, one of the four types listed below that indicate the percentages of medical costs paid by your health plan.

  • Gold – Medical costs paid by health plan: 80%, medical costs paid by you: 20%. Gold plans usually have higher premiums but cost you less out-of-pocket for medical services.
  • Silver – Medical costs paid by health plan: 70%, medical costs paid by you: 30%
  • Bronze – Medical costs paid by health plan: 60%, medical costs paid by you: 40%. Bronze plans typically have lower premiums but cost you more when you use medical services.
  • Catastrophic Plans– Can be purchased by consumers under the age of 30 and by those who qualify for hardship exemptions. These plans are designed to protect you from worst-case scenarios like serious illnesses or accidents.

The first three types of plans are all required to meet state and federal standards to cover ten Essential Health Benefits (EHBs) including doctor visits, hospitalizations, emergency services, mental health and substance abuse services, rehabilitative and habilitative services, maternity and newborn care, lab tests, prescriptions, preventive care and screenings and pediatric care.

The “Coverage For” line will tell you who your plan covers, e.g., you, you + spouse, entire family, etc. This is important because deductibles and out-of-pocket expenses vary by the number of people covered by your plan.

The next section,” Important Questions”, will provide you with the information you’ll need to budget for your health insurance needs including things like how much you’ll pay for services before your plan starts paying each year, how much you’ll pay for deductibles for in-network vs. out-of-network care and deductibles you’ll pay for prescriptions.

The SBC will also give you some examples of typical costs for common medical events like office visits, pregnancy and lab tests including how the costs will differ if you use an out-of-network provider. It will list common (though not all excluded services).

Finally, you’ll see an outline of your rights as a health consumer and information about how to file a grievance or appeal.

Go ahead and break out your SBC and you’ll be on your way to getting the most out of your health insurance coverage!


Categories: Blog