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.”