Jeffrey Wade
When it comes to choosing a health insurance plan, one of the most important documents to understand is the Summary of Benefits and Coverage (SBC). This document outlines what is and isn't covered by a health plan, as well as the associated costs. All insurance companies are required to provide an SBC for each of their plans, and it is designed to make it easier for consumers to compare and choose the right health plan for their needs. The SBC includes coverage examples, simulating how a plan would cover common medical situations such as diabetes care and childbirth. This document is often referred to as an Explanation of Benefits (EOB) and is usually provided alongside a billing statement from a healthcare provider. While the EOB is not a bill itself, it helps consumers understand how their insurance has processed their claim and how their bill has been calculated.
| Characteristics | Values |
|---|---|
| Name | Summary of Benefits and Coverage (SBC) |
| Purpose | To outline what is covered and not covered under a health plan |
| Format | Four double-sided pages with 12-point type |
| Language | Plain language, simple and consistent |
| Availability | Available in multiple languages |
| Coverage Examples | Diabetes care and childbirth |
| Contents | A statement on whether the plan meets minimum essential coverage (MEC) for the Affordable Care Act (ACA); a statement on whether it meets a minimum value (plan covers at least 60% of medical costs); personal details such as name, member number, and plan information; information about the visit, including dates and type of care received; a breakdown of charges for services |
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What You'll Learn
Summary of Benefits and Coverage (SBC)
The Summary of Benefits and Coverage, or SBC, is a document that outlines what is covered under a health plan and what is not. All health plan companies are required to provide an SBC for each of their different plans. The SBC is designed to help consumers compare costs and understand coverage options when shopping for health plans. It includes details such as covered benefits, cost-sharing provisions, and coverage limitations and exceptions.
The SBC is typically four double-sided pages long and is created using a standard outline that all health plans must follow. This standard format makes it easier for consumers to compare different plans and choose the one that best suits their needs. The SBC also includes coverage examples, which illustrate how the plan would cover care in common medical situations, such as diabetes care and childbirth.
In addition to the SBC, insurance companies and group health plans are also required to provide a Uniform Glossary of terms used in health coverage and medical care. This glossary helps consumers understand commonly used insurance terms such as "deductible" and "co-payment". The SBC and the Uniform Glossary together help consumers make informed decisions about their health insurance choices.
Consumers can obtain an SBC from their insurance company or group health plan at various points, such as when shopping for coverage, enrolling in a plan, or renewing their policy. It is also possible to request a copy of the SBC at any time and even in a language other than English. The SBC is a valuable tool for consumers to understand their health plan benefits and make informed decisions about their healthcare choices.
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Explanation of Benefits (EOB)
An Explanation of Benefits (EOB) is a document that explains how your insurance provider processed your claim for the services you received. It is not a bill, but it is a useful tool that shows you how your bill is divided between the medical service provider(s), your insurance, and you. It can help ensure that you are receiving the full benefit or discount that you are entitled to under your insurance plan.
An EOB typically includes personal details such as your name, member number, and plan information. It also includes information about your visit, such as the date(s) of service, the name of your doctor or clinic, and the type of care you received (e.g., preventive care or office visit). The EOB will also contain a breakdown of the charges for the service(s) received, so you can see how much your insurance company paid and the amount you owe.
It is important to note that the formatting of an EOB statement may vary depending on the insurance company. Additionally, you may receive multiple EOBs if you received more than one type of service or treatment during the same visit or on different days. It is recommended to save your EOBs until you receive the final bill from your doctor or healthcare provider. Insurance companies often provide online access to past EOBs for their members.
In some cases, you may receive a bill from your doctor or healthcare provider before receiving the EOB. This typically occurs when your doctor's office does not have your insurance information or when you visit an out-of-network provider. It is recommended to wait for the EOB before paying any bills to ensure that you are not paying more than you owe. If there is a discrepancy between the EOB and the bill, you should contact your doctor or insurance company for clarification.
EOBs are important documents that help you understand how your insurance plan covers the medical services you receive. They provide a breakdown of the charges and payments, ensuring that you are only paying for the amount you owe. By comparing the EOB with your billing statement, you can identify any potential errors or discrepancies and resolve them accordingly.
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Glossary of Health Coverage and Medical Terms
A Glossary of Health Coverage and Medical Terms, also known as a Uniform Glossary, is a document that defines commonly used terms in health insurance plans and policies. While it is intended to be educational, it is important to note that the terms and definitions in the glossary may differ from those in your specific plan or policy, and it is always the policy or plan that governs.
The glossary can be a helpful tool when choosing a health insurance plan as it allows you to compare plans based on costs, benefits, and other important features. It provides definitions for terms related to deductibles, coinsurance, and out-of-pocket limits, as well as eligible expenses, payment allowances, and negotiated rates. Additionally, it clarifies the meaning of "individual mandate," which refers to the requirement for individuals to enrol in health coverage that provides minimum essential coverage.
Minimum essential coverage typically includes plans available through the Marketplace, Medicare, Medicaid, CHIP, TRICARE, and certain other coverages. It is important to note that if you are offered an employer plan that covers at least 60% of the total allowed costs of benefits, the plan offers minimum value, and you may not qualify for premium tax credits or cost-sharing reductions when purchasing a plan from the Marketplace.
The Glossary of Health Coverage and Medical Terms also includes definitions related to health care services. These definitions clarify the types of services that are covered, such as habilitation, diagnosis, treatment, and symptom management. Additionally, the glossary defines the term "providers," referring to the facilities, providers, and suppliers with whom your health insurer or plan has contracted to provide health care services.
While the glossary provides a comprehensive list of terms, it may not cover every term used in health insurance. It is always recommended to refer to your specific plan or policy document for the most accurate and up-to-date information regarding your coverage.
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Affordable Care Act (ACA)
The Affordable Care Act (ACA), also known as the Patient Protection and Affordable Care Act or Obamacare, was signed into law on March 23, 2010, as healthcare reform. The ACA is not health insurance but rather a law that reforms the insurance system to help more people obtain health coverage and protect consumers.
The ACA has several key provisions. Firstly, it requires insurers to cover a list of essential health benefits (EHBs), including emergency services, family planning, maternity care, hospitalization, prescription medications, mental health services, and pediatric care. There are no annual or lifetime dollar limits on coverage for EHBs, and insurance companies must spend at least 80% of premium dollars on actual medical expenses. Secondly, the ACA expands access to health insurance for those who were previously uninsured due to pre-existing conditions or limited finances. It prohibits insurance plans from excluding coverage for individuals with pre-existing conditions and prevents insurers from denying coverage due to these conditions. Additionally, the ACA establishes insurance "exchanges" or marketplaces where individuals can purchase health insurance policies, with options to fit different budgets.
The ACA also includes provisions to make health insurance more affordable. It provides consumers with subsidies, known as "premium tax credits," that lower costs for households with incomes between 100% and 400% of the federal poverty level (FPL). These subsidies are available for those who purchase private insurance, and Medicaid has been expanded to include more people, including single adults and all adults with incomes below 138% of the FPL.
Furthermore, the ACA addresses preventive care by requiring insurance plans to cover services such as immunizations, preventive care for children, and screenings for certain conditions. The Prevention and Public Health Fund was established to provide grants to states for prevention activities, and there is also a mandate for a public education campaign on oral health.
Overall, the ACA represents a significant step towards meaningful health system reform, aiming to increase health insurance coverage and improve access to affordable, comprehensive healthcare for millions of Americans.
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Coordination of Benefits (COB)
COB applies when expenses for covered services are eligible under more than one insurance program. Usually, one health insurance company has primary responsibility, and there is at least one other health insurance company with responsibility for any remaining patient liability. The primary plan pays your claims as if there were no other insurance. Then the secondary plan pays for what the primary plan did not, providing it is a covered benefit. For example, if a doctor's visit costs $80 and your health plan, which is primary, pays $50, your secondary health plan could pay the remaining $30.
Special rules apply for COB where the Horizon policy is an insured group policy issued by Horizon 11:4-28.7, as amended effective January 1, 2003, provides for different COB rules (as to insured group policies issued in New Jersey) depending on what basis the primary and secondary plans pay and whether the physician is or is not in the network of either or both plans. If none of the above provisions determines which plan is primary, the plan covering you the longest is typically considered primary.
When a patient has more than one plan, it is important to get the insurance health plan company name, policyholder name, member ID, and employer name for each plan. It is also important to advise your patient to inform their insurance company of other coverage. When Medicare is primary, Medicare Part A and Part B claims can be submitted electronically.
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Frequently asked questions
SBC stands for Summary of Benefits and Coverage. It is a document that outlines what is covered under a health plan.
An SBC includes information such as coverage examples, which show what the plan would cover in common medical situations, and a statement on whether the plan meets minimum essential coverage.
Insurance companies and group health plans are required to provide an SBC at important points in the enrollment process, such as when you apply for or renew your policy. You can also request a copy from your insurance company or group health plan at any time.
EOB stands for Explanation of Benefits. It is a document that explains how your insurance processed a claim for the services you received. It is not a bill, but it will show you how your bill is broken down between the medical service provider, your insurance, and you.
