Summary of benefits and coverage

A Summary of Benefits and Coverage (SBC) describes what an insurance plan covers and the cost of various treatments.  The first page includes the name of the insurance carrier, the plan name, and the coverage period. The rest of the document lists categories of covered services and their associated costs. For questions about specific services and exclusions, call your insurance carrier at the phone number on the back of your member ID card. 

If you're enrolled in Gusto-brokered health insurance, follow these steps to find your SBC and other benefit details in Gusto:

  1. Sign in to your Gusto employee account.
  2. Go to the Benefits tab.
  3. Click the benefit you'd like to review.
  4. Click the link next to "Plan Name."

Here are the most important terms you'll find in an SBC and what they mean. 

Deductible

A deductible is the amount of money you have to pay out-of-pocket for covered healthcare services until your insurance company starts to pay. Example: if your plan has a $2000 in-network deductible, you must pay the first $2000 of your in-network care. Some plans have an exception to the deductible for certain services. On the first page of the SBC, look for a row that says "Are there services covered before you meet your deductible?" If any services are listed, this means that instead of having to pay 100% for that service until the deductible is met, you'll only have to pay the coinsurance or copay listed for that service. 

After you meet the deductible, many plans will still have you pay for a portion of any care you receive. You cover your share of the cost through copayments,  coinsurance, or a combination of the two. 

Pay particular attention to when the deductible resets. It either resets on the calendar year (January 1st) or the plan year (the plan's renewal date), depending on what was set up when your company applied for group coverage. The reset means you'll need to meet your deductible again before the insurance carrier starts covering services.

Out of Pocket Maximum (OOP)

The OOP max is the most money that you will pay for covered services during a plan year. This OOP Max does not apply to treatment that your health insurance doesn't cover. For example, if you have an HMO plan and you see a doctor who is out-of-network, your insurance will not contribute because HMO plans do not cover out-of-network services. Therefore, any expenses you incur for out-of-network treatments will not be included in the calculation of your OOP Max. The example below shows a member whose OOP max is $2,500 for an individual or $5,000 for a family plan.

Coinsurance and copayments

SBCs usually have a table that describes common medical events and how much you’ll need to pay for those treatments. Coinsurance is the percentage of the total cost of the treatment that you are required to pay.  Copayments are fixed dollar amounts that you pay for covered treatments. Below is a sample chart on an SBC showing coinsurance and copayments. Participating vs. Non-Participating Provider means that your doctor is in- or out-of-network with your insurance carrier. Some plans will cover part of these visits and others won't.

In- and Out-of-Network treatment

Your SBC will specify whether or not your plan has a network of providers. This means that the insurance carrier has negotiated a fixed price for treatment with specific doctors. These doctors are “in-network.”  Some plans will cover out-of-network treatment, but only after meet a separate, higher out-of-network deductible. Be very careful about this detail of your health insurance plan because it can be very costly to you if you seek out-of-network treatment and you have a plan that only covers treatment in-network. The easiest way to find a doctor who is in-network is to enter "[carrier name] provider search tool" in your search engine. 

Prescription drug coverage

Each insurance carrier has a formulary of prescription drugs that dictates what tier each drug is in. The tier dictates how much the member will pay for the drug. Your SBC will show you how much copay and coinsurance you will pay for differently tiered drugs. The example below shows the different tiers and how much the member will pay for in- and out-of-network pharmacists. If the member needs a non-preferred brand drug (tier 3) from an in-network provider and the drug costs $100, the member can expect to pay $40 and the insurance will cover the remaining $60. The fourth column describes any limitation or exception to the coverage.

Pregnancy

This section will usually be toward the end of your SBC. It will let you know what your coinsurance is for in- and out-of-network pregnancy-related care. In the example below, the member can expect to pay 40% of a prenatal treatment from a doctor who is out-of-network.

Other treatments

This section usually appears at the end of your SBC as well. Typically this is where you will find coverage for treatments like acupuncture, chiropractic care, cosmetic surgery...etc. The SBC will let you know whether or not these treatments are covered but you will need to determine the actual coverage by reviewing the Evidence of Coverage that you can request from your carrier.

Note: This article is intended to be used as an example to help you understand your Summary of Benefits & Coverage and is not a description of your specific plan. To view your SBC, please sign into your Gusto account and click the Benefits tab where you will find your plan details.