If you find health insurance confusing, rest assured, you are not alone. From uncommon terms to complex grids of benefits to cost share percentages, many people have trouble fully understanding their health plan coverage. In fact, one study shows that over half of the adults surveyed felt at least one part of their health insurance was difficult to understand. Let’s demystify your health plan by walking through where to find your benefits information and how to decode it.
Summary of Benefits and Coverage
Your best source of information is your health plan’s Summary of Benefits and Coverage (SBC). It’s an easy-to-understand overview of benefits and coverage provided by a health plan. Health insurance companies are required to provide this document for all plan types so that prospective and current members know their benefits and are also able to compare plans more easily. With that said, there’s still a lot of to unpack in this document. Below you’ll find an explanation of each section.
Plan Information
The SBC starts with general information about a plan. This includes the type of plan it is, dates the coverage is active, and who is covered. In addition, the introduction directs you to where you can find term definitions that will be used in the document.
Important Questions
Following the general plan introduction is a section called Important Questions. It clarifies your share of costs for care like your deductible and out-of-pocket maximums. Additionally, this section explains the plan’s use of in-network and out-of-network providers and your access to each.
Common Medical Events
Next is a grid of common medical scenarios, what you’ll pay for each, and any rules or limitations associated. You can use this section to really get into the nuts and bolts of a plan and determine if its coverage is right for your current health needs and budget.
Exclusions
Some medical services are not covered by your plan such as cosmetic surgery, long-term care, coverage when you travel, and routine eye care. The SBC will outline what those are and what that means for you. Sometimes what’s not covered is just as important for you as what is so make sure to review this section, too.
Coverage Examples
People learn differently. To ensure that everyone fully understands a plan, the SBC includes examples of coverage for specific medical conditions or events. One coverage and cost share example may be living with type 2 diabetes and another may be having a baby.
Prescription Drug Coverage
If a plan includes prescription drug coverage, the SBC will direct you to a formulary or list of covered drugs and cost-sharing to review. Take the time to review that document even if you don’t have any prescriptions as that could change.
Rights to Continued Coverage
This section lets you know that you have a right to continued coverage unless you move out of the coverage area, don’t pay your premiums, or fraud the insurer. A carrier cannot take away your coverage because of any health issues.
Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: [insert State, HHS, DOL, and/or other applicable agency contact information]. Other coverage options may be available to you, too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit www.HealthCare.gov or call 1-800-318- 2596.
Where and When to Review Your SBC
Now that you know the basics of a SBC, you can review it when you want to confirm your current coverage or compare coverage options. You can access your current plan’s SBC on MyVEBA. With Open Enrollment starting, you should be provided a new one soon. Under the Affordable Care Act, the SBC must be distributed with enrollment forms. If there is an auto-renew of a plan, employers must provide the SBC within 30 days of the plan beginning. Sometimes plans change coverage during the year. You’ll receive a new SBC with those changes at least 60 days in advance. So make sure to review any important plan inform
Working Together for Your Healthiest Life
If you find this blog helpful in understanding health insurance and the open enrollment period, be sure to check out the other blogs in this series for more in-depth information here.
Get Support: The VEBA Advocacy Team can help you review your health plan and discuss it with you in depth. Call 888-276-0250 or visit vebaonline.com/contact for assistance. For urgent requests, use the “Urgent” box on the contact form.
MyVEBA Portal: Easily view your current health plan information through the MyVEBA app or online portal. Download the app for Apple or Android, or visit the MyVEBA Portal for desktop access.
Benefit Contacts: For assistance with specific carrier benefits or issues, such as claims or coverage details, visit vebaonline.com/benefit-contacts to contact them directly.
