Use the plan summary.
Every group health plan has a Summary of Benefits and Coverage. It is the one document designed to be compared, and most employees have never been shown how to read it.
Four rows to teach employees to find.
Federal law requires the summary so that plans can be compared on the same footing.
The deductible and out-of-pocket rows
These set the threshold and the ceiling for the year. Teach employees where they sit and what each means.
The common medical events table
Primary care, specialist, emergency room and hospital stay are listed with what the employee pays for each. It is the closest thing to a price list.
The coverage examples
The summary shows sample costs for having a baby and managing diabetes. They turn the numbers into scenarios.
The network and referral notes
The summary says whether a referral is needed and how out-of-network care is handled. It answers questions employees do not know to ask.
What the rules say.
The figures and requirements below come from the federal sources cited at the end of this section. General information, not legal advice.
No more than four pages
The summary of benefits and coverage must be in a uniform format, no more than four pages, in at least 12-point type, written so the average enrollee can follow it.
Defined terms and coverage examples
It carries uniform definitions of standard insurance terms and coverage examples for common scenarios such as having a baby or managing a chronic condition.
It is not the governing document
The summary says on its face that the full plan document or certificate controls, and gives a phone number and web address for it.
Changes require advance notice
A material change that is not reflected in the latest summary requires notice to enrollees at least 60 days before it takes effect.
Sources: 42 U.S.C. 300gg-15
We put the summary in front of employees and teach the rows.
We highlight the rows that matter on your plans and walk employees through them, so the summary becomes a tool and not a stack of paper.
Related pages.
The Summary of Benefits and Coverage, Explained
What the SBC is and how to read it.
Explain Benefits Before Employees Enroll
The most effective fix for plan confusion is also the simplest: explain the plan before the enrollment window opens, with a real example, in words employees already use.
Health Plan Terms That Sound Alike
Copay and coinsurance, deductible and out-of-pocket maximum, premium and cost of care.
Avoiding Group Health Insurance Plan Confusion
The full guide to helping employees understand their group health plan.
Questions that come up next.
Short answers to the questions employees ask after this one. Each links to its own page.
Does explaining the plan change what it covers?
No. Explanation does not change coverage. The plan documents, the carrier contract and the summary of benefits and coverage decide what is covered. What explanation changes is whether employees choose the plan that fits them and know how to use it.
What should employees see before open enrollment?
At minimum: the summary of benefits and coverage for each option, a plain definition of the key terms, a side-by-side of premium and likely cost, a way to check their doctors against the network, and a named person to ask.
Do copays count toward the deductible?
It depends on the plan. On some plans copays count toward the deductible and on others they do not. Copays generally do count toward the out-of-pocket maximum for covered in-network care, but confirm in your plan documents.
Ready? Send us your renewal, or talk it through with someone first. No cost, no obligation.
General information about group health plan terms, not legal or tax advice. Plan-specific questions belong with the plan documents and the carrier.
Send us your renewal.
We’ll tell you whether it looks competitive, where we see opportunity, and the five questions we’d put to your carrier. No cost, and no obligation to move anything.
The renewal letter
Your current plan summary
Contribution split by tier
Enrolled counts by tier
Four documents, two more if your group is 50 or more. Nothing else; every extra one is a reason to postpone.
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