The summary of benefits and coverage document details the specific coverage and exclusions of a health insurance plan. Health insurance companies are required to provide the document under the Affordable Care Act. Insured individuals can call the insurance company directly to ask about specific coverage and benefits.
Summary of benefits and coverage documents follow a standard format using simple language, allowing consumers to easily compare policies. Required information includes deductible, out-of-pocket limit, copayments, coinsurance, specialty visits, coverage exclusions, network of providers and coverage differences for in-network versus out-of-network providers. The form breaks down the coverage to explain the benefits for different types of medical procedures and care.
The document is also required to provide coverage examples for two standard health care protocols: having a baby and managing type 2 diabetes. The sample breaks down specific costs and how much of the costs that plan would cover.
Most health insurance companies make the summary of benefits and coverage document available online in addition to mailing a copy. Individuals insured by the company can also call the customer service line to get information about specific coverage. Customer service representatives can clarify confusion or explain how a specific medical procedure is covered by the policy.