How to Read a Summary of Benefits and Coverage
When the Affordable Care Act was introduced, regulators wanted to make things as easy as possible for consumers, so they included a section to summarize the benefits and coverage for each plan. If you’re evaluating health insurance plans and are looking at your options, you can use this section to compare like-for-like without needing to delve into lengthy and sometimes complex documentation. What can you expect to find in this summary?
Describing the Plan
As you may know, there are four primary plan types: HMO, EPO, POS, and PPO. Your plan will be identified at the top of the summary, in addition to the projected coverage period. It also tells you who the plan covers, whether it’s for an individual, individual and spouse, individual and couple, or family. Your deductibles and out-of-pocket maximums will vary according to the number of people in the plan.
Asking Important Questions
You will then find important information about your overall deductible and whether any specific deductibles relate to items like pharmaceuticals. You’ll also find the out-of-pocket maximum (the most the plan will ask you to pay each year) and whether there is an overall limit per year on what the plan will pay.
Other key questions tell you whether the plan requires you to get a referral before you can see a specialist or if there are any particular services the plan does not cover.
Describing Examples of Common Events
You may then find a section that gives you examples. For instance, how much are you likely to pay for commonplace medical events, such as an office visit?
Viewing Exclusions and Covered Services
Next, look for information about exclusions and other covered services. This list may not be comprehensive, and you may need to refer to the detail in the plan itself. For example, your plan may not include dental or vision services or any cosmetic surgery.
Summarizing the Benefits
Towards the bottom of this summary, you should find examples that will help you imagine certain scenarios. For example, when you have a baby, it will detail the individual care costs leading up to the grand total. It will then show how much you need to pay through deductibles, co-payments, or coinsurance.
Getting More Information
Ideally, this summary of benefits and coverage will help you analyze each plan so that you can make a more informed decision. If you need more guidance, contact a United Benefits Specialist by filling out the form below.