How to Read a Summary of Benefits and Coverage for Health Insurance

If you’re looking for a new health insurance plan and unsure about what to ask for, don’t worry — we’ve got your back. In this post, you’ll find a summary of the different components of coverage.

You may find that a plan’s coverage is nearly identical to your last one. If you’ve been with the same insurance company for years, you’re likely getting a similar plan with a few changes here and there. The best way to figure out if you’re getting a new plan is to look at the summary of benefits, also known as the SBC. This is a standardized summary of the plan’s benefits, including preexisting health conditions, maternity coverage, and other important information. According to the Centers for Medicare and Medicaid Services (CMS), every health plan sold to individuals and small groups must provide an SBC in a uniform format so consumers can make meaningful comparisons.

Before the SBC is given to you, you may have to fill out an application. The application acts as your contract with the insurance company, so make sure that you understand everything before signing it. Suppose you have any questions or concerns after reviewing the SBC and signing the application. In that case, you may want to speak with your insurance company representative about them.

If you are unsure about any health issues or questions, discuss them with your doctor before signing the application. If your doctor has a different opinion from the one in the application, let them know. Some doctors are very protective of what their patients get from their insurance companies. Still, others will support you if there’s a discrepancy between what is suggested in the application and what your doctor recommends. If this happens, explain why you think the decision is wrong to ensure that it doesn’t affect coverage for any future medical conditions that may arise.

Another thing you should always look out for is if there are any limitations or exclusions to your policy. You may want to visit as many listings as possible and check the fine print. For example, some policies may exclude from coverage any prescription medications that you’ve already received or had prescribed for you under the previous policy. The HealthCare.gov glossary of excluded services is a useful reference when reviewing what a new plan will and won’t cover. Don’t be afraid to ask about this — it’s not uncommon for a new plan to have exclusionary terms to encourage consumers to switch from the more expensive, standalone prescriptions of the old policy to a more cost-efficient plan with multiple co-pays and deductibles.

When reviewing your new policy, remember that a provider may ask for referrals from your primary care doctor. This is generally not an issue, but if you’ve moved recently, you may find that your old primary care doctor no longer accepts the plan. In this case, it’s a good idea to keep a list of alternate providers who accept the plan and will not raise any red flags with your insurance company. Many large insurers — including those offering plans through the federal Health Insurance Marketplace — publish searchable provider directories online to help you verify in-network status before you commit.

Always be prepared to ask plenty of questions when looking for a new plan. If you’re not sure what to ask, we’ve made it easy by providing you with a list of important questions that you can always rely on. Before signing the application, make sure you understand each component of your plan: how much coverage do they offer, are there any limits or exclusions, and should I contact my doctor about this? Remember that a representative from the insurance company will have the answers to these questions for you.

Here is a breakdown of some elements from an SBC to understand what it means.

What Is Covered?
If there is anything that you’re wondering whether you’ll be covered for, chances are it’s on here. The most common coverage includes dental care, eye care, mental health services, prescription drug coverage, and more. Under the Affordable Care Act’s ten essential health benefits, all marketplace plans are required to cover categories including hospitalization, emergency services, preventive care, and pediatric services.

What Is Not Covered?
This is one of the most important sections of the SBC. Be sure to read through this section carefully to ensure that you are not paying for any services that will not be covered. Some things you might not be covered for include dental and vision care, weight loss or cosmetic surgery, or even certain mental health treatments. If there is anything you think will not be covered, ask about it before signing up for the plan. The National Association of Insurance Commissioners (NAIC) offers a consumer guide that explains common exclusions across different plan types.

How Much Does It Cost?
This section may seem confusing at first, but don’t worry — we’ve got your back. Included in this section is an “out-of-pocket maximum.” This refers to the maximum dollar value of the plan that you will have to pay for covered services.

The out-of-pocket maximum varies from plan to plan. For 2026, the ACA out-of-pocket maximum is $9,200 for individual coverage and $18,400 for family coverage, as set by the Centers for Medicare and Medicaid Services (CMS). To find out your specific out-of-pocket maximum, check the plan’s summary of benefits and coverage that you received when you signed up for the plan.

How Often Can I Go to the Doctor?
You can visit a physician or a specialist as often as medically necessary. Ask your insurer how often they have a system in place where you can see a specialist without needing to see your primary care physician first. This is also sometimes called an “urgent care” visit. Plans sold through insurers like UnitedHealthcare or regional Blue Cross Blue Shield affiliates typically outline visit frequency rules directly in the SBC’s limitations section.

What Is My Deductible?
Your deductible is the amount you have to pay out-of-pocket before your insurance company covers the rest. For example: if your plan has a $1,000 deductible and you get an X-ray that costs $100, your insurance company will only cover $900 of costs once you’ve reached your deductible. If you haven’t yet met your deductible, the remaining amount is on you. According to KFF’s 2025 Employer Health Benefits Survey, the average annual deductible for single coverage in employer-sponsored plans was $1,735.

How Much Will My Co-Pay Be?
Most plans include co-pays for various services and medications prescribed by a physician. They’re usually listed on your SBC in the “Other Doctor’s Fees” area. The Department of Labor’s consumer guide on health plan costs explains the difference between co-pays, coinsurance, and deductibles in plain language, which can be helpful when reviewing your SBC.

How Much Can I Go Over My Limit?
This section is different for each plan. They may include how much of a particular medication you can take, how much coverage you have for prescriptions, or even how many days you can have a medical emergency. The CMS SBC Instructions outline how insurers must disclose benefit limits in a standardized way. Be sure to read the plan’s Summary of Benefits and Coverage to ensure that these limits are what you expect them to be.

Deposit or Deposit Refund?
This might be confusing at first, but your deposit or deposit refund is any money you pay into your health insurance plan in advance — whether it’s money toward your deductible or the premium itself.

Some plans will refund a portion of your deposit when you cancel the policy. If you plan on canceling your policy, be sure to ask if you will receive a refund. The rules around premium refunds and cancellation are also governed at the state level by your state’s insurance commissioner — a directory of all state regulators is maintained by the National Association of Insurance Commissioners (NAIC).

What is the Renewal Date?
This is particularly important if you have a small business health plan or large group coverage. It’s important to renew these plans with your insurance company before the end of their term — otherwise, you’ll have to go through the whole application process again. Be sure not to miss that deadline. The federal open enrollment guidelines also govern when individuals on marketplace plans can make changes outside of their renewal date.

What is covered if My Spouse or Child is covered?
In some cases, having one family member covered through your health plan might also cover other family members. For example, if one of your adult children is covered through your plan, their spouse and children (if any) are also insured. Ask your insurance company how they define a “family member,” and be careful not to get overcharged for a specific service. Under current HHS rules, adult children can remain on a parent’s health plan until age 26, regardless of student or marital status.

Frequently Asked Questions

What is a Summary of Benefits and Coverage (SBC)?

An SBC is a standardized, easy-to-read document that health insurers must provide to all applicants and enrollees. It summarizes what a health plan covers, what it costs, and what is excluded. The Affordable Care Act requires all insurers offering individual and small group plans to provide an SBC in a uniform format so consumers can compare plans side by side.

When am I required to receive an SBC?

Insurers are required to provide the SBC before you enroll or re-enroll in a plan. You should also receive an updated SBC at least 60 days before a material change to your plan takes effect. If you request an SBC at any time, the insurer must provide it within seven business days.

What is the difference between a deductible and an out-of-pocket maximum?

Your deductible is the amount you pay for covered services before your insurance begins to share costs. Your out-of-pocket maximum is the absolute most you will pay in a given plan year — once you hit that cap, your insurer covers 100% of covered services for the rest of the year. For 2026, the ACA out-of-pocket maximum is $9,200 for individuals and $18,400 for families.

What is coinsurance and how is it different from a co-pay?

A co-pay is a flat dollar amount you pay at the time of a covered service, such as $30 for a specialist visit. Coinsurance is a percentage of the total cost you pay after meeting your deductible — for example, 20% coinsurance on a $500 procedure means you pay $100. Both terms should be clearly defined in your SBC’s cost-sharing section.

Are dental and vision care covered under a standard health insurance SBC?

Standard health insurance plans typically do not include comprehensive dental or vision coverage for adults — these are generally sold as separate, standalone plans. However, pediatric dental and vision coverage is one of the ten essential health benefits mandated by the Affordable Care Act for marketplace plans. Your SBC’s “Not Covered” section will specify this clearly.

What does “in-network” vs. “out-of-network” mean on an SBC?

In-network providers have contracted rates with your insurer, meaning you pay lower cost-sharing amounts. Out-of-network providers have not agreed to those rates, so your costs are typically much higher — and some plans won’t cover out-of-network care at all except in emergencies. Your SBC will show separate cost columns for in-network and out-of-network services so you can compare directly.

What are the ten essential health benefits every ACA plan must cover?

Under the Affordable Care Act, all marketplace and most employer plans must cover: ambulatory patient services, emergency services, hospitalization, maternity and newborn care, mental health and substance use disorder services, prescription drugs, rehabilitative services, laboratory services, preventive and wellness services, and pediatric services (including dental and vision for children). These benefits must appear in your SBC.

Can I be denied coverage for a preexisting condition?

No. Since 2014, the ACA has prohibited insurers from denying coverage or charging higher premiums based on preexisting health conditions for plans sold in the individual and small group markets. Your SBC should not contain any language that limits coverage based solely on a preexisting condition for ACA-compliant plans.

What is a premium tax credit and does it appear in my SBC?

A premium tax credit is a subsidy available to individuals and families with incomes between 100% and 400% of the federal poverty level who purchase coverage through the Health Insurance Marketplace. The credit reduces your monthly premium. The SBC itself shows the full plan cost before credits are applied — your actual premium after credits will be shown in your Marketplace enrollment confirmation. The IRS provides guidance on eligibility through its Premium Tax Credit overview.

How do I compare two SBCs side by side?

The best way is to use the standardized coverage examples section included in every SBC, which shows estimated total costs for common scenarios such as having a baby or managing type 2 diabetes. Compare the same scenarios across both plans to get a realistic cost picture. The HealthCare.gov plan comparison tool also allows side-by-side SBC comparisons for marketplace plans.