Navigating the Summary of Benefits and Coverage

The Summary of Benefits and Coverages (SBC) outlines information about health plan benefits and coverage in simple terms. The SBC allows individuals to understand the terms of a health plan while providing the ability to easily compare different plans. Additionally, it will explain essential features of the plan or coverage, including the covered benefits, cost-sharing provisions, and coverage limitations and exceptions. SBCs will also include coverage examples that illustrate how the plan handles claims for specific scenarios and will be helpful for consumers to see how valuable the plan will be at times when they may need coverage.

Health insurance issuers will provide the SBC at the following times:

  • When shopping for coverage,
  • Enrolling in coverage,
  • At each new plan year, and
  • Within seven business days of requesting a copy from a health insurance issuer or group health plan.

Note: This is the standard format for all SBCs up until April 1, 2017. Health plans and issuers are required to use the new SBC template beginning on the first day of the first open enrollment period that begins on or after April 1, 2017. For plans that do not use an annual open enrollment period, the new SBC template is required beginning on the first day of the first plan year that begins on or after April 1, 2017. For more information, visit this Department of Labor page.

Deductible Thumbnail

Deductible, Out-of-Pocket Limits, Networks, and Referrals

PCP

Primary Care Doctor and Specialist Visits, Preventive Care, Tests

prescription_drugs

Prescription Drug Coverage, Surgical/Hospital Stays, Emergency Coverage


mental_health

Mental/Behavioral Health, Maternity, Rehabilitation, and Special Needs

MEDICAL_EQUIPMENT
Medical Equipment, Pediatric Dental/Vision, Excluded and Other Covered Services

COBRA
COBRA Continuation Rights, Minimum Essential Coverage, Minimum Value Standards

coverage_examples
Coverage Examples: Having A Baby and Type 2 Diabetes Management

q&a
Q&A about Coverage Examples


Where to Find the Summary of Benefits and Coverage

Finding the Summary of Benefits and Coverage (SBC) in Zenefits is easy. Depending on whether an employee is enrolling for the first time or going through Open Enrollment, or if ... Learn more

SBC - Deductible, Out-of-Pocket Limits, Networks, and Referrals

The SBC explains the deductibles for individuals and families, annual out-of-pocket limits, whether a provider network is used, and if certain services require referrals. Rec... Learn more

SBC - Primary Care Doctor and Specialist Visits, Preventive Care, Tests

The SBC explains the coverage level for seeing primary care doctors and specialists, as well as what's covered under preventive care. This will also detail what the plan covers... Learn more

SBC - Prescription Drug Coverage, Surgical, Hospital Stays, Emergency Coverage

The SBC explains the different benefits depending on the different tiers of prescription drugs, benefits regarding surgeries and hospital stays, and coverage for visits to Emer... Learn more

SBC - Mental and Behavioral Health, Maternity, Rehabilitation, Special Needs Services

The SBC explains how the plan covers mental and behavioral health services, pre- and post-natal benefits, as well as the coverage for special needs services. This is the stan... Learn more

SBC - Medical Equipment, Pediatric Dental and Vision, Excluded Services and Other Covered Services

The Summary of Benefits Coverage (SBC) explains the coverage for durable medical equipment, whether or not the plan covers dental and vision services for children, and goes ove... Learn more

SBC - COBRA Continuation Rights, Appeals, Minimum Essential Coverage

The SBC explains an enrollee's right to continue coverage under COBRA, how to submit appeals or file a grievance for claims, and confirms whether or not Minimum Essential Cover... Learn more

SBC - Coverage Examples

The SBC gives two common examples of how the plan would pay for coverage: having a baby, and managing Type 2 Diabetes. This is the standard format for all SBCs up until April... Learn more

SBC - Coverage Example Q&A

The SBC goes over some frequently asked questions about the Coverage Examples on the previous page This is the standard format for all SBCs up until April 1, 2017. Please ref... Learn more

Still need our help? Our support team is waiting to help you. Contact us