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.
- What services are covered under my insurance policy?
- How can I find out what’s covered under my insurance plan?
- What does my health insurance company or job-based plan have to disclose to me about my health coverage?
- What’s in a Summary of Benefits and Coverage (SBC)?
- When can I get an SBC?
- What other information may I need to make a decision about coverage?
- Can I get the SBC in languages other than English?
- Will this SBC change throughout the year?
- What if I have more questions?
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.
Coverage for Preventive Care
Under the Affordable Care Act, new health plans must cover certain preventive services without cost sharing.
Coverage for Pre-Existing Conditions
- Children’s pre-existing conditions: In many states, your individual insurance policy might permanently exclude coverage for pre-existing conditions, including disabilities. However, under the Affordable Care Act, new individual insurance policies (and job-based plans) are not allowed to exclude coverage for pre-existing conditions or disabilities in children under age 19.
- Pre-existing conditions for anyone: Starting in 2014, these same policies will not be allowed to exclude coverage for pre-existing conditions for anyone.
- Temporary exclusions in job-based plans: If you have job-based health coverage, the plan is allowed to exclude coverage temporarily for pre-existing conditions, including disabilities, usually for no more than one year. If you had other coverage before joining your current plan, it must be credited toward the pre-existing condition exclusion period. Note: In 2014, for job-based plans, waiting periods for coverage of pre-existing conditions will be limited to 90 days.
Coverage for Pregnancy under Job-Based Plans
Under your job-based plan, pregnancy cannot be considered a pre-existing condition. In addition, newborns and adopted children who are enrolled within 30 days of birth or adoption cannot be subject to a pre-existing condition exclusion. Learn more about HIPAA’s preexisting condition exclusion period.
Coverage under Small Employer Policies
For small employer insurance policies, states vary on what they require insurers to cover. Contact your State Department of Insurance for more information about small employer coverage requirements in your state.
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.
More Information on What’s Covered
- If you have questions or concerns about what’s covered under your job-based plan, you can contact the U.S. Department of Labor. Their benefits advisors can help you get answers to questions about your rights under federal law.
- If you have individual insurance, find consumer assistance in your state for more information about your coverage rights and protections.
What does my health insurance company or job-based plan have to disclose to me about my health coverage?
They must give you a Summary of Benefits and Coverage – or SBC – under certain circumstances. The SBC is designed to be easy to understand. They must also provide access to a uniform glossary of common insurance and medical terms. If your health coverage, as reflected in the SBC, changes in the middle of a year, then they must also provide a notice 60 days in advance.
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.
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 other information may I need to make a decision about coverage?
To make coverage decisions you will also want to check the premium and see if it the health plan will provide access to your doctors and cover your prescription drugs. In addition, health insurance issuers or plans may provide you with additional information to help you make your decision.
Can I get the SBC in languages other than English?
In some parts of the country, the SBC can be requested in Spanish, Chinese, Tagalog, and Navajo. If more than 10% of the people in your county speak one of these languages, the English version of the SBC will indicate how you can get the non-English SBC.
Will this SBC change throughout the year?
Maybe. If there are any major changes to the benefits or costs as described in your SBC, your health insurance company or job-based health plan must send you a notice 60 days before the change takes place.
What if I have more questions?
Contact your health insurance company or job-based health plan. The SBC lists their contact information.