Taking Control Before You Enroll

A reminder: On or about 23 September 2012, most health insurance plans and insurers will be required to supply you with a Summary of Benefits and Coverage (SBC).  This SBC is designed to make your life easier by offering a snapshot of the medical coverage the plan you are considering (or already have) in action.  This means that the covered health benefits, some of your costs and up-to-date information about your particular network of doctors and providers are all spelled out in clear and comprehensible language.

A big part of this effort to make buying health insurance coverage less about guesswork and hope and more about understandable plan design and real, usable options is a tool called Coverage Examples.  A coverage example tells the story of a sample patient facing two common medical situations – in the news release, for instance, we have a woman having a baby while managing her type 2 diabetes.  The example sets up sample care costs for both situations, side-by-side.  It explains what a typical co-pay might amount to for a diabetes management drug, while also detailing the total estimated patient costs for a normal delivery.  What the patient pays is clearly delineated; what the plan in question pays is cleared delineated.  This is not a cost estimator, simply an example.  The idea is that having a sample patient to relate to, during the course of a commonly experienced event, makes the role health insurance will play more understandable.

The SBC will also include a list or glossary of terms and words commonly used by health insurers.  They are all to use the same terms, too,  so that when you compare terms, you are using a genuinely apples-to-apples approach.

It has been the federal government’s mission for a while now to be sure the SBC is a trustworthy, reliable and functioning tool.  Consumers, insurance commissioners, the federal government and healthcare industry representatives all worked together on the development and design of the SBC.  Time will tell if it really helps, but it certainly can’t make it any harder than it already is!

Under the law, you may receive an SBC:

  • When you shop for health insurance coverage.
  • When employers shop for coverage to offer their employees.
  • When you are choosing options among job-based plans.
  • If you (or your family) are shopping for or using insurance in the individual market.
  • If you are an employer who gets coverage from an insurance issuer.
  • If you and your family are currently covered by an employer plan.

Your employer or insurance company must provide an SBC (depending on your situation) before you purchase or enroll in coverage, before coverage is renewed, and when you request it.  If you obtain health insurance coverage through an employer, your employer will have a copy of your SBC.  If you buy your coverage individually, outside of work, your insurance company will have your SBC.  And in some parts of the country, you should have access to an SBC in Navajo, Tagalog, Chinese and/or Spanish.

The benefits of an SBC?  As consumers, we should all benefit because the SBC is designed to:

  • Help us better understand our coverage.
  • Help us better compare and contrast options.
  • Help use find the best coverage for ourselves and our families.
  • Help employers find the best coverage for their businesses and their employees.
  • Reduce the difficulty of finding and comparing coverage information.
  • Encourage health insurance issuers to compete on price, quality and benefits.

Special thanks, newsroom.


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