The Summary of Benefits and Coverage (SBC) is simple and standardized comparison document required by the Patient Protection and Affordable Care Act (PPACA). All insurance plans are required to produce a Summary of Benefits and Coverage based on a uniform template and customized to reflect the plan’s unique terms.
If you need a paper copy, call 1-877-7-NYSHIP (1-877-769-7447) and select the Medical Program. Your HBA, usually located in your agency’s personnel office, can also print you a copy.
Terms defined in the Uniform Glossary
Some words on the Summary of Benefits and Coverage are shown in bold and underlined. These terms are defined in the Uniform Glossary, a non-customized companion document to the SBC. Click here to view a PDF copy that can be printed as necessary. These definitions are intended to help improve consumer understanding and do not necessarily reflect your plan’s definition of the same term. Refer to your plan material for the definition used by your plan.
Contents of the Summary of Benefits and Coverage
The Summary of Benefits and Coverage is a standardized template and the cells cannot be altered, moved, or deleted by any plan. There are four major sections – Important Questions, Common Medical Events, Excluded Services & Other Covered Services and Coverage Examples. The Coverage Examples are for Having a Baby and Managing Type II Diabetes and are based on presumptions of what services a person may receive over a year of each scenario. These numbers are industry based using government guidelines. These Coverage Examples do not reflect the actual cost of either scenario.
Click on the link below to access the Summary of Benefits and Coverage for the following:
Q. Can I get a paper copy of the Summary of Benefits and Coverage if I need one?
A. Yes, if you need a paper copy of the Summary of Benefits and Coverage for The Excelsior Plan or a copy of the Uniform Glossary, call 1-877-7-NYSHIP (1-877-769-7447) and select the Medical Program.
Q. Should I use the Summary of Benefits and Coverage to decide which health insurance option is best for my family?
A. No. The Summary of Benefits and Coverage is a simple, federally mandated table intended to aid consumer understanding. This document does not provide the full scope of coverage under any plan and should not be construed as a complete description of a plan's benefits. Always refer to other plan material, such as your Empire Plan At A Glance for more information about The Empire Plan if you are making a decision about your family's coverage.
Q. Will my Summary of Benefits and Coverage explain how services are covered?
A. Your SBC may provide you with some information that will explain how you are covered for certain services, such as what your copayment is. However, for a complete list of covered services and more comprehensive information explaining how services are covered, refer to your Empire Plan Certificate, At A Glance and other plan material.
Q. I see that the Coverage Examples page shows a "you pay" amount. Is this what I will pay if I have a baby or manage Type II Diabetes for a year?
A. It's unlikely that you would pay the same amount listed in the "you pay" cell of the Summary of Benefits and Coverage. The Coverage Examples that are included in the SBC are based on a standard set of services that a patient might receive in either scenario. These Coverage Examples are intended to help you compare your overall coverage and are not intended as a cost estimator.