Whats Covered Under a Plan ?

Services Covered and Summary of Benefits and Coverage (SBC)

No matter what kind of coverage you have, it’s important to know what’s covered and what’s not. Starting in 2014, certain essential health benefits will be covered under all policies. In the meantime, the new law offers new options for preventive coverage and insurance for those with pre-existing health conditions.

Source: Healtcare.gov

What services are covered under my insurance policy?

It depends on what policy you buy.  Coverage under many individual policies today can be very limited.  This will change.

Starting in 2014, new individual plans and plans purchased in an Affordable Insurance Exchange will have to cover essential benefits like hospitalizations, doctor services, prescription drugs, rehabilitation and mental health services, pregnancy, and newborn care. Also, there will be limits on how much you have to pay out-of-pocket each year for covered services.

An Affordable Insurance Exchange is a new marketplace where individuals and small businesses can buy affordable health benefit plans. Exchanges will offer you a choice of plans that meet certain benefits and cost standards.


How can I find out what is covered in my insurance plan?

Read your policy.  Often this is hard to do.  Insurance policies can be complex documents and not always easy to follow.  Call your insurance company for more information about what your policy covers.

Starting in 2012, all insurance papers must be written in clear and understandable language that explains what’s covered and how it works, so you can understand your choices more clearly and decide what coverage is really best for you.

Health Plan Summaries

  • Summary plan descriptions:  Job-based health plans are required to provide a summary plan description to all members. The summary plan description explains what the plan covers, what costs you are responsible for, how to appeal disputes, and other important information. Sometimes claims procedures are in a separate booklet that‘s handed out with your summary plan description.
  • Questions on job-based insurance? Ask your benefits office or plan administrator at work for help with problems or questions about your job-based health plan. The Department of Labor website has more information on job-based plans.

What’s in a Summary of Benefits and Coverage (SBC)?

An SBC is a summary of the benefits that your plan covers, with the cost-sharing associated with that coverage. An SBC has the following information:

  • Answers to important questions about your coverage.
  • Your costs for common medical services.
  • Services not included in your coverage.
  • New shopping tools called “coverage examples.” These coverage examples illustrate how your coverage would pay for the medical care in two common situations. One situation is a woman having a baby, and the other is an adult managing type 2 diabetes.
  • Standard definitions for some common insurance and medical terms, and information on how to obtain the uniform glossary.
  • An explanation of your rights to continue coverage.
  • An explanation of your rights if you have complaints or are dissatisfied with a denial of coverage.
  • Information for contacting your company or plan, including getting a copy of your contract, learning about your network of providers (if you have one), and finding out about your prescription drug coverage.
  • A notice that because the SBC is only a summary, you should consult your plan document, policy, or certificate of insurance to find out more details about your cost sharing and benefits under the contract.

When can I get an SBC?

In general, your health insurance company or job-based health plan must give you an SBC in the following situations:

  • When you make a request.  You may make the request at any time before or after you enroll.  Once the company or plan receives your request, they must send the SBC within seven business days.
  • When you apply for coverage.
  • Before the first day of coverage if there are any changes in SBC information.
  • At annual renewal.

Insurance companies and job-based health plans will begin rolling out SBCs on or after September 23, 2012.  The date you receive your SBC may be different because the rules vary by plan or issuer types.

What if I have more questions?

Contact your health insurance company or job-based health plan.  The SBC lists their contact information.

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