This article is for employees who want to understand their medical benefits and find their Summary of Benefits and Coverage.
A Summary of Benefits and Coverage (SBC) is a document your insurance carrier creates. It explains what your insurance plan covers and how much different services cost. The first page of an SBC includes your insurance carrier's name, the plan name, and the coverage period. The rest of the document lists covered services and their costs. At the end, your carrier includes a few medical scenarios and their costs, like pregnancy, a simple fracture, and diabetes management.
If you have questions about specific services or exclusions, call your insurance carrier. You can find the phone number on the back of your member ID card. If you're enrolled in benefits through Gusto, you can also find your carrier's contact info in the Benefits section of your account.
Note: This article helps you understand your Summary of Benefits and Coverage. It's not a description of your specific plan. To view your SBC, sign in to Gusto and go to the Benefits section, where you'll find your plan details.
If you're enrolled in Gusto-brokered health insurance (including the broker integration), you can find your SBC and other benefit details in your Gusto account.
To find your SBC in Gusto:
Go to Benefits.
If you do not have this tab, your company might not offer benefits through Gusto, or you may not be eligible. Contact your company administrator for more info.
Find the benefit you want to see and click View.
In the top-right corner, click See plan document.
Your Summary of Benefits includes important insurance terms. Here are the most common terms and what they mean.
Your plan type determines how many doctors and hospitals you can choose from. It also shows you if your plan covers visits outside your network. You can find your plan type at the top of your Summary of Benefits or in the plan name in Gusto.
These are the four main types of health insurance plans. Each plan type has different rules about which doctors you can visit and whether you need referrals.
Preferred provider organization (PPO)
A PPO plan usually lets you visit any in-network doctor or healthcare provider without a referral from a primary care doctor first. PPOs also offer some out-of-network visits. But you need to meet a separate, higher deductible before out-of-network care is covered. You pay the least when you visit in-network providers. PPOs offer the most choices of doctors and hospitals. Because of this, they usually cost more than other plan types.
Health maintenance organization (HMO)
An HMO usually costs less but has fewer doctors and hospitals to choose from. Most HMOs require you to get a referral from your primary care doctor before you visit a specialist. HMOs usually do not cover out-of-state or out-of-network services, except in an emergency.
Exclusive provider organization (EPO)
An EPO is a health plan that lets you get in-network treatment without needing a referral from a primary care doctor to visit a specialist. EPOs do not cover treatment from out-of-network providers, except in an emergency.
Point of service (POS)
A POS plan is often a mix of a PPO and an HMO. Many POS plans require you to see a primary care doctor before you visit a specialist. A POS plan may cover some out-of-network treatment, but in-network providers usually cost you less.
Note: POS plan features vary by carrier. For example, many of UnitedHealthcare's POS plans work more like PPOs. Most include out-of-network coverage and do not require a referral to visit a specialist.
Health insurance plans are divided into four metal tiers. These tiers show you how much your insurance carrier will pay for your in-network healthcare costs. Plans that cover a greater share of your healthcare costs have higher premiums. Plans that cover less cost less each month.
The Affordable Care Act (ACA) sets a percentage of healthcare costs that each metal tier must cover.
Bronze plans must cover at least 60% of essential health benefits. Bronze plans have the lowest premiums.
Silver plans must cover at least 70% of essential health benefits, unless you qualify for a cost-sharing reduction.*
Gold plans must cover at least 80% of essential health benefits.
Platinum plans must cover at least 90% of essential health benefits. Platinum plans have the highest premiums.
*Silver plans are different. You may qualify for a cost-sharing reduction subsidy. Depending on your income, this subsidy could qualify you for a silver plan that covers about 73, 87, or 94 percent of your healthcare costs.
A High Deductible Health Plan (HDHP) is an insurance plan with lower premiums and a higher deductible. When you enroll in an HDHP, you can put pre-tax funds in a Health Savings Account (HSA). You add funds to an HSA through pre-tax payroll deductions and can spend them on qualifying medical expenses.
If your plan has HDHP or HSA in its name, as listed in your SBC or in Gusto, it's a High Deductible Health Plan. If your employer offers an HSA, you can enroll in it after you choose an HDHP in Gusto.
Check your Summary of Benefits for your plan's exact benefits. Remember that many HDHPs only pay for preventive care until you meet the deductible. Until then, you pay 100% for things like specialist visits and prescriptions. The benefits are that you'll usually pay less in premiums, and you can use your pre-tax HSA funds on qualifying out-of-pocket expenses.
Each plan has its own provider network. This is where you pay the least for covered services.
After you know your plan type (PPO, POS, EPO, or HMO), you need to know the name of your provider network. A medical network is a group of hospitals, doctors, pharmacies, and specialists. Your insurance carrier pays them a set amount for their services. Visiting in-network providers costs the least.
To find your network, look at your plan name in your SBC or in Gusto. Examples: Anthem BlueCard PPO, UnitedHealthcare Select Plus network, Humana HMO Select, Kaiser HMO.
Find a provider
Before you go to the doctor or health facility, check your carrier's provider search tool to find in-network doctors and facilities. You can search for "[carrier name] provider search" in your web browser, check your member portal, or call your carrier directly.
Your insurance carrier sets fixed rates for hospitals, doctors, pharmacies, and specialists in your network. This means you pay less for in-network treatment.
If your plan covers out-of-network care, you'll have a separate, higher out-of-network deductible and out-of-pocket maximum. You pay 100% of out-of-network care until you meet that higher deductible (unless it's emergency care).
Even if your plan does not usually cover out-of-state or out-of-network care, you pay the same for emergency room services at an out-of-network hospital. You pay the same rate as in-network emergency treatment.
Emergency care is treatment for a medical condition that requires urgent care to keep it from worsening. If the situation needs attention right now to prevent death or severe harm, then it's considered an emergency.
After you know your plan type and network, use your SBC to learn what different healthcare services will cost you.
Preventive care is routine health care that helps keep you healthy and prevent disease, disability, and death. The Affordable Care Act requires all health plans to cover a set of preventive services at no cost to you. This means you do not pay a copay or coinsurance, and you do not even need to meet your deductible for certain preventive services.
Common examples include:
Annual physicals (including women's health visits and well-child visits)
Immunizations/vaccinations
Recommended screenings
Diet and alcohol misuse counseling
Learn more about approved preventive care services from Healthcare.gov.
A deductible is the amount you pay for covered healthcare services until your insurance company starts paying.
After you meet the deductible, your carrier starts paying for part of your in-network care. You cover your share of the cost through copays, coinsurance, or a combination of the two.
Some plans have an exception to the deductible for certain services. On page 1 of your SBC, look for a row that says "Are there services covered before you meet your deductible?" If any services are listed, you pay only the coinsurance or copay for each service. You do not pay 100% until you meet the deductible.
Pay attention to when the deductible resets. It resets on either the calendar year (January 1) or the plan year (the plan's renewal date). This depends on what your company chose when they applied for group coverage. When the deductible resets, you need to meet the deductible again before the insurance carrier starts covering services.
The out-of-pocket maximum is the most you pay for covered services during a plan year. Once you meet your max, you do not pay copays, coinsurance, or other costs for covered services for the rest of the year.
Your out-of-pocket maximum resets at the same time as your deductible. It resets either to the calendar year or your plan year.
The out-of-pocket max does not apply to treatment that your health insurance does not cover. For example, if you have an HMO plan and you visit a doctor who is out-of-network, your insurance will not pay because HMO plans do not cover out-of-network services. Any expenses for out-of-network treatments do not count toward your out-of-pocket max.
Your SBC lists your copays or coinsurance for different services. Starting on page 2, look at the columns for "Services You May Need" and "What You Will Pay" to find your copays or coinsurance for different services.
Remember, you may need to meet your deductible before copays and coinsurance apply. At the top of page 2, look for this phrase: "All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies." This means you pay 100% at first unless the SBC says otherwise. Once you meet the deductible, your insurance carrier will start covering part of the in-network costs. You pay the listed copay or coinsurance.
Copay
A copay is a fixed dollar amount you pay for a particular service. For example, if the "Specialist visits" section of your SBC lists a $75 copay, you pay $75 if you visit a dermatologist after you meet the deductible. Before you meet the deductible, you pay 100% of whatever your dermatologist charges for the visit.
Coinsurance
When the "What You Will Pay" column shows a percentage, this is coinsurance. Coinsurance is a percentage of each service's total cost that you pay. If your coinsurance is 40% for an office visit, you pay 40% of the doctor's charge. Your carrier pays the other 60%.
Pre-authorization is approval from your health insurance carrier. It confirms your plan will cover the medical treatment or medication you want before you get it.
Note: Some carriers require pre-authorization for certain services. Make sure to work with your doctor or pharmacy to get this approval before you receive treatment. This helps you get the most out of your health insurance.
Each insurance carrier has a formulary. This is a list of prescription drugs that describes how your plan covers each drug. The tier shows how much you pay for the drug. Your SBC shows how much copay and coinsurance you pay for drugs in different tiers.
To confirm the tier of a specific drug and how much you pay for it, contact your insurance carrier or sign in to their member portal.
To find an in-network pharmacy, sign in to your insurance carrier's member portal or call your carrier.
This section usually appears toward the end of your SBC. It shows your coinsurance for in-network and out-of-network pregnancy-related care.
This section usually appears at the end of your SBC. This is where you find coverage for treatments like acupuncture, chiropractic care, or cosmetic surgery. The SBC shows if your plan covers these treatments. You need to check the Evidence of Coverage document to learn the actual coverage. You can request this document from your carrier.
Outside of your Summary of Benefits, here are other terms you'll come across with your medical insurance.
The contribution scheme (also known as the contribution strategy) is the amount of money your employer contributes to your benefits. Your company's contract with the insurance carrier includes this amount. Your company cannot change the amount until it renews benefits at the end of the plan year.
You can find your contribution scheme in the Benefits section of your Gusto account.
No employer with fewer than 50 full-time employees has a minimum contribution requirement. If your company has 50+ employees, it likely needs to follow the employer mandate of the Affordable Care Act, including the "Employer Responsibility" provision.
If your company contributes less than 100% of employee premiums, you pay the remaining portion through payroll deductions. Your company keeps this money in its bank account to pay the insurance premiums in one lump sum.
An insurance claim is a request for payment. You or your doctor can submit it to your carrier when you get items or services you think your plan covers. Contact your carrier directly to file a claim. Most carriers let you file claims through your online portal, or you can call their member services number for instructions.
When your carrier receives a claim, they process it based on your plan details. After that, you get an Explanation of Benefits. This shows what your insurance paid for and what you still owe.
A premium is the total monthly cost for your insurance plan. If your company contributes to your premiums, you pay your share of the remainder through payroll deductions.
Health insurance carriers require a minimum percentage of all eligible employees to enroll in the employer-sponsored health plan. If an employee declines coverage for a valid waiver reason, the carrier does not count them in the total employee count. This means they do not count against the participation requirement.
Examples of valid waiver reasons most carriers accept include:
Other group coverage through a different employer
Other group coverage through a spouse or parent
Enrolling as a dependent in your employer's group health plan
Coverage through Medicare
Coverage through Medi-Cal
Coverage through Tricare
Note: Most carriers do not consider having individual health insurance a valid waiver reason.
A waiting period is the amount of time a newly eligible employee must wait to become eligible for benefits after their hire date. For people who have recently gone from part-time/ineligible to full-time/eligible, their waiting period starts on the day they became full-time/eligible. For example, say a company's waiting period is "1st of the month after hire," and someone is hired on January 15. Their first day of insurance coverage would be February 1. Newly eligible employees can choose their plan in Gusto as soon as their Gusto account is set up.
The waiting period is specified in a company's contract with the health insurance carrier and cannot be changed until the company renews benefits at the end of the plan year. If you choose to update the waiting period during renewal, it will apply to all new hits for the following year.