Lost in translation: How to decode your Summary of Benefits and Coverage

24284604 - portrait of a worried young couple looking at paperCommunications related to health insurance can seem like they’re written in another language. Among them may be your Summary of Benefits and Coverage. If you purchase health insurance on the government exchange, you should receive this summary regardless of your plan. Most private insurers also offer one, or provide a similar document. Understanding it, however, is an entirely different matter.


Deductibles are how much you pay “out of pocket,” before the plan’s coverage kicks in. Typically, there is an overall yearly deductible, but there may also be deductibles for specific services, or for out-of-network providers.

Out-of-pocket maximum

The out-of-pocket maximum is the most you pay out-of-pocket per year for all covered medical expenses. Once you reach it, your plan pays 100% of your covered costs. There may be a different maximum for in-network and out-of-network providers.

Annual limit

Annual limits are the most that plans will pay for certain covered services. Although there are no overall annual limits on government-exchange plans, certain services, such as those for mental health, may be capped at a specific number of visits.

Still have trouble decoding your Summary of Benefits and Coverage? Talk to your health insurance broker to get a “translation.”

Picking a plan with a health insurance broker


It’s time to choose a health care plan. You’ve done the smart thing, and contacted a health insurance broker. But how do you work with them to get the plan that’s best for you?

Comparison shop

One way to narrow down the list of possible plans is to ask yourself, “Is seeing the same doctors I see now important to me?” If the answer is “yes,” you’ll want to look at provider networks that list them – especially the ones that have them “in network.” This will lower your potential health care costs for the year.

Know your rights

If you’re considering buying a plan on the government exchange, ask your broker if you’re eligible for any cost-saving measures. This may include subsidies, which require a subsidy application. Your broker should be able to help you complete this application.

Don’t break down in “tiers”

Does the plan or plans you’re thinking of buying use drug formularies? If so, they may be broken down into tiers. Medications under different tiers may have different costs. Review these tiers and costs with your health insurance broker for any medications you take regularly, or are likely to need in the future.

What are the biggest questions YOU have for a health insurance broker when it comes to choosing a plan?