5 Consumer Tips to Navigate New ‘Summary of Benefits and Coverage’ Forms

Written by on November 30, 2012 in Features - No comments

eHealthInsurance, America’s first and largest private health insurance exchange, released its top five tips to help consumers navigate the new “Summary of Benefits and Coverage” forms in accordance with provisions of the 2010 Affordable Care Act (ACA). Many consumers will come into contact with these new forms for the first time as they review and compare health insurance plans during this year’s open enrollment season.

Health insurance companies are required to make copies of the new Summary of Benefits and Coverage forms available to consumers for each health insurance plan they sell beginning September 23, 2012. The intent of the new forms is to provide consumers with a standardized, easy-to-understand description of how benefits and costs are balanced by each health insurance plan, and to help consumers make informed purchasing and enrollment decisions.

“Translating health insurance terminology into language the average person can understand helps consumers make the right coverage decisions for their personal needs.” said Gary Matalucci, eHealthInsurance Vice President of Customer Care.

The new Summary of Benefits and Coverage forms answer basic consumer questions (like “What is the overall deductible?” or “Does this plan use a network of providers?”) and explain why answers to these questions matter. They describe “common medical events” (such as visiting a doctor’s office, needing prescription drugs, or staying overnight in the hospital) and explain how much a patient may be required to pay for these services. The forms also provide a list of medical services excluded from coverage, and an estimate of the total patient responsibility for medical bills incurred in case of pregnancy and delivery, or for the management of Type 2 diabetes.

The final template for the Summary of Benefits and Coverage forms produced by the U.S. Department of Health and Human Services is six pages long and it’s recommended that health insurance consumers review the whole form before making a final plan selection. The highlights and tips provided below were selected to provide a summary guide to items of special consumer concern.

Top Five Things to Look for on the New Summary of Benefits and Coverage Forms:

1. The Maximum Out-of-pocket Limit. What would happen if you became seriously ill or suffered an accident and suddenly found yourself facing serious hospital bills? The maximum out-of-pocket limit (MOOP) describes the upper limit of your personal financial exposure per year under a particular plan. Once you reach your maximum out-of-pocket limit, the health insurance company picks up all bills for most covered, medically necessary expenses. A typical MOOP ranges between $5,000 and $7,500. Be sure that, if the worst happened, you could afford your MOOP. Note that the maximum out-of-pocket limit does not include your monthly premiums. To find a plan’s MOOP on the new Summary of Benefits and Coverage form, look under “Important Questions” and find the question: “Is there an out-of-pocket limit on my expenses?”

2. The Deductible. The deductible is an amount you must pay out-of-pocket each year for specified medical services before the health insurance company steps in to provide coverage. Monthly premiums and copayments do not apply toward the deductible. Not all medical care is subject to the deductible, however. Many preventive care services, for example, are covered by most plans even before you meet your deductible. Some health insurance plans may also have more than one deductible. For example, some may have separate deductibles for in-network and out-of-network physicians. Others may have a separate deductible for prescription drugs. The new Summary of Benefits and Coverage form addresses deductibles in the “Important Questions” section.

3. The Cost of a Doctor’s Office Visit When Ill. Since many people only see the doctor when sick, it’s important to understand your level of coverage for these visits. When reviewing the new Summary of Benefits and Coverage form, you will find this addressed in the section describing coverage for common medical events. Make sure you understand what your copayment is when visiting an in-network or out-of-network physician, and whether your doctor’s office visit is subject to your annual deductible.

4. The Network of Providers. Many health insurance plans – especially HMOs and PPOs – contract with medical provider networks to negotiate discounted charges for patient care. It’s important to know if the plan you’re considering restricts your access to doctors, and whether or not your preferred doctor is covered by the plan. Under the “Important Questions” section of the new Summary of Benefits and Coverage form, you’ll find information about provider networks and covered doctors. If there are differences in coverage between in-network and out-of-network providers, these differences should be described in the “Common Medical Events” section of the form.

5. Coverage for Prescription Drugs. In order to pick up a prescription drug from the pharmacy, most health insurance plan members are required to make a copayment or pay a percentage of the drug’s total cost. Some health insurance plans may have a separate deductible for prescription drugs. Many, however, have different coverage tiers for different kinds of drugs. Make sure you understand how much you’ll be required to pay for generic drugs, preferred brand-name drugs, and other drugs, before you enroll in a plan. Information about prescription drug coverage is found in the new Summary of Benefits and Coverage forms in the section describing common medical events.

There is a great deal of complexity to health insurance coverage and many consumers will not readily understand how to judge between two different plans. It’s recommended that consumers considering their health insurance alternatives work with their employer’s Human Resources department or contact a licensed health insurance agent, like eHealthInsurance.com, for personal assistance and advice.


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