Plan documents can run to dozens of pages, and every plan used to present its benefits differently. The Summary of Benefits and Coverage, or SBC, was created to fix that. It is a short summary of a plan's benefits and costs, in a standard format, so that two plans can be compared like for like. Learning to read one is probably the most useful single skill for understanding a health plan.
This explainer follows the HealthCare.gov glossary and the Department of Labor's page on the SBC and the uniform glossary, which publishes the standard template and instructions that plans use. The section names below describe that template; an individual plan's SBC fills it in with its own numbers.
What an SBC is
Under the Affordable Care Act, health insurers and group health plans must give people an SBC that describes the plan's benefits and coverage in plain language. Every SBC uses the same template, in the same order, with the same headings. That standardisation is the point: the deductible is always in the same place, and so is the out-of-pocket limit.
Alongside the SBC, plans must make available a uniform glossary of common insurance and medical terms, so that words like "coinsurance" and "allowed amount" mean the same thing from plan to plan. The glossary on this site explains the same kinds of terms in plain English.
The SBC is a summary, not the contract. It says so itself, and the full plan documents control if the two disagree.
Getting one
Plans and insurers must provide the SBC free of charge. You will usually receive it, or be pointed to it, when you are looking at or enrolling in a plan and when coverage renews, and you can ask for it at other times. For job-based coverage, the employer's benefits office or the plan administrator can supply it; for an individual plan, the insurer or the Marketplace listing for that plan.
The top of the form
The first lines name the plan and the insurer, show the coverage period (the plan year the summary applies to) and say who the coverage is for, such as an individual or a family, and the plan type. Check the coverage period first: an SBC for last year's plan may have different numbers.
The important questions
The first page has a table of important questions, each with the plan's answer and a note on why it matters. They are the core cost and access facts of the plan, in a fixed order:
- What is the overall deductible? The amount you pay for covered services before the plan starts to pay, usually with separate individual and family figures.
- Are there services covered before you meet your deductible? Preventive care and some copay services often are.
- Are there other deductibles for specific services? For example, a separate deductible for prescription drugs.
- What is the out-of-pocket limit for this plan? The ceiling on your yearly cost sharing for covered care.
- What is not included in the out-of-pocket limit? Typically premiums, balance-billed charges and care the plan does not cover.
- Will you pay less if you use a network provider? Whether the plan uses a network, and where to find its provider list.
- Do you need a referral to see a specialist? Whether a primary care referral is required.
Those seven answers tell you most of what the cost explainer, the out-of-pocket explainer and the plan types explainer cover, in a few lines. Note what the table does not include: the premium. The SBC describes cost sharing; the premium comes from the plan's price listing or your employer.
The medical events table
The longest part of the SBC is a table organised by common medical events, such as visiting a doctor's office, having a test, needing drugs, having outpatient surgery, needing immediate medical attention, a hospital stay, mental health or substance use services, pregnancy, recovery or other special health needs, and a child's dental or eye care.
For each event, the table lists the services you might need and what you would pay for each one with a network provider and with an out-of-network provider. A final column holds limitations, exceptions and other important information, and it is worth reading closely. It is where you find things like a limit on the number of visits, a note that preauthorization is required, or a statement that a service is not covered out of network.
Read the "what you will pay" cells carefully. "20% coinsurance" usually means after the deductible. "$30 copay" may or may not apply before the deductible; the cell or the important questions table will say. "Not covered" means the plan pays nothing for that service.
The prescription drug rows usually list a cost for each drug tier, such as generic, preferred brand, non-preferred brand and specialty drugs. The drug tiers explainer explains those levels.
Excluded and other services
After the table comes a short list of services the plan generally does not cover, such as cosmetic surgery or long-term care, depending on the plan. A second list names other covered services that might not be obvious, sometimes with limits. Excluded services matter because their cost sits entirely outside the plan, including outside the out-of-pocket limit.
Rights and coverage standards
The later sections describe your rights to continue coverage, how to file a grievance or appeal if the plan denies a claim, and where to get help. They also answer two technical questions: whether the plan provides minimum essential coverage and whether it meets the minimum value standard. Those answers matter mainly for eligibility for premium tax credits and are explained further on HealthCare.gov. The form also includes language access information.
The coverage examples
The SBC ends with coverage examples: standard scenarios that show how the plan would share the cost of a realistic episode of care. The template uses three of them: having a baby with in-network care, managing a year of routine care for well-controlled type 2 diabetes, and treating a simple fracture with an emergency visit and follow-up care.
Each example shows a total cost for the episode and how much the patient would pay, split into deductibles, copayments, coinsurance and anything the plan does not cover. Because every plan's SBC uses the same scenarios and the same assumed total cost, the examples are a direct way to compare two plans.
They have limits. The total costs are illustrative and are not estimates of what care costs where you live, and the examples do not include premiums. They show how a plan's rules interact, not what you will actually spend.
Comparing two plans
Illustrative example: made-up numbers, not a real plan or SBC
Imagine two SBCs side by side. Plan A shows a $1,500 deductible and a $6,000 out-of-pocket limit; Plan B shows a $4,000 deductible and a $7,000 limit. In the having-a-baby coverage example, Plan A's total patient share is shown as $2,500 and Plan B's as $4,500. Separately, Plan A's premium is $150 a month higher than Plan B's, which is $1,800 more a year.
Reading across: for a year with that kind of care, Plan A's higher premium is more than offset by $2,000 less cost sharing. For a year with very little care, Plan B's lower premium would likely leave it cheaper overall. The figures are invented for the comparison and do not come from any real SBC.
A simple routine for comparing SBCs:
- Confirm both cover the same coverage period and the same people.
- Line up the seven important questions, row by row.
- Find the rows in the medical events table for the care you expect to use and compare them.
- Read the limitations column for those rows.
- Compare the coverage examples, then add each plan's yearly premium yourself.
- Check the provider directory for the doctors and hospitals that matter to you; the SBC does not list them.
The SBC tells you how a plan works. Whether a plan suits someone depends on things it cannot know, and this site does not recommend plans.
Next: Drug lists and tiers: how prescription coverage is priced