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Understanding Your Benefits And Coverage Summary

As part of the 2010 Affordable Care Act or Obamacare, a toolwas created called the Summary of Benefits and Coverage—or the SBC.  The ACA created the SBC tool to aid enrolleesin understanding better what their health plan does and does not cover.  

The information in the SBC is presented in a uniform andconcise manner, so much so that it can also be handy when comparing differentinsurance plans.  The SBC is simply aquick snapshot of your plan's overall coverage that doesn't need you to diveheadfirst into any complex documents that your insurance provider may provide.

Each plan under the ACA will provide its members with a copyof their benefits and coverage summary. If you are having difficulty locating the SBC for your particular healthinsurance plan, reach out to your provider.

Basic Information

At the top of the first page of the summary of benefits andcoverage form will be the name of the company the insurance is provided by andthe name of the plan itself.  Alsocontained within the header is the coverage period that the plan is goodfor.  

Plan Type

The type of plan will also be provided, such as if it is aPPO, HMO, EPO, or POS.  Knowing the typeof plan you have will aid you in determining which physicians fall within thenetwork of the plan and the contact information for each of them.

Who Is Covered

Next will be the information that confirms the individualcovered by the plan—whether the coverage is for a single individual or for anentire family.  Locating this informationwill become essential when reading your SBC, as deductibles and out-of-pocketexpenses will be determined by the number of individuals attached to the plan.

Important Questions

Next, you see a section labeled "importantquestions."  The area lays out yourobligations financially and more about this plan.  Any essential information you may need whenbudgeting is clearly laid out on the SBC's first page.

Deductible Specifications

Contained in this section is information on your overalldeductible.  The comprehensive deductibleis how much you will be required to pay out of your pocket each year before theplan will kick in and begin delivering on covered services.  In most cases, both an individual and afamily deductible will be shown on the SBC. The information will also correspond to the "coverage for"area previously mentioned, located at the top of the SBC form.  Also included are both in-network andout-of-network deductibles, but they will not apply to preventative carecoverage.

Depending on the specific care required, most plans willrequire separate deductibles—such as the costs of prescriptions orpharmaceuticals.  With these areas, youwill be required to meet a separate deductible for any pharmaceutical costsbefore the plan kicks in, providing payment in this area of medical expenses.

Maximum Out-Of-Pocket

With most insurance plans, once you have covered apredetermined amount of your medical costs on your own, they will kick in andtake the majority of the load.  Commonlyreferred to as the out-of-pocket maximum, this is the most amount of money theplan will require you to spend out of your pocket.  Keep in mind that determining theout-of-pocket maximum does not include any of the medical bills that maycurrently be covered and paid by the plan. Much like a deductible, the maximum will differ from plan to plan forin-network and out-of-network charges.

Annual Limits

Any medical plan created or came into existence after 2014does not currently have any limits on what they will pay on an annual basis.  Contained within the SBC will be informationthat will show the yearly limits overall and state that there will be a limitannually to what the plan will pay on medical costs.  However, the plan may limit specificservices, such as those performed by a chiropractor or any mental healthvisits.

Provider Network

Most health insurance plans on the market today use what isreferred to as a "provider network." When a plan makes just of a provider network, it will strongly suggestthat you use a physician within the network.  By visiting a physician outside of theapproved network, you may be required to cover a separate deductible or highercosts for treatment.  Visiting aphysician outside the approved network is not allowed with some plans.

Specialist Referrals

The process for referrals will most often depend on yourchosen plan.  Programs such as HMOs willrequire a referral before being able to see a specialist.  Yet other programs will allow you the choiceof visiting a specialist without requiring a referral.  If a referral is needed, and you choose tosee a specialist anyway, the plan may subject you to charges out of your ownpocket.

Here at Savvi, our mission is to help people take the stressout of buying health insurance in Houston, Texas, San Antonio, Dallas, Ann Arbor, and Grand Rapids.  Feel confident by knowingthat you'll have the absolute best plan that fits your lifestyle &budget.  We look forward to working withyou.