This article is intended for members enrolled in an individual health insurance plan.
For answers to basic questions about your health care coverage, look at your health plan’s Summary of Benefits and Coverage (SBC).
You should have received your SBC when you enrolled in your plan. SBCs describe key features such as the covered benefits, cost-sharing provisions, and coverage limitations and exceptions of your plan. Information in SBCs represents an overview of your coverage.
You can also find your SBC by logging in to Blue Access for MembersSM (BAMSM). After you log in, you will see a My Coverage tab. When you click on that tab, there is a My Coverage box on the left. Select Medical. A link to your SBC will be below your plan name.
The table on page one of your plan’s SBC starts with Important Questions in the first column and Answers in the second column. The third column, Why This Matters, explains how the answer may affect you.
The next pages of the SBC show Common Medical Events in the left column. These range from doctor office visits and tests to emergency care and hospital stays. The SBC also includes details about drug coverage.
Then the SBC lists Services You May Need for each common medical event.
The What You Will Pay column is split into Participating Provider (in network) and Non-Participating Provider (out of network). Generally, you will pay less when you use a participating provider (in network).
If you have an HMO plan, you will see “not covered” in the Non-Participating Provider column. Note there may be exceptions for emergency care in some cases.
The last column, Limitations, Exceptions, & Other Important Information, provides examples of when your benefit may not apply or special steps you may need to take to use that benefit.
The SBC also lists Excluded Services, which are common services that are not covered by your plan, as well as Other Covered Services.
The Coverage Examples are one of the most useful parts of the SBC. These examples break down costs for different medical events. First, the examples list plan deductibles, copays and coinsurance. Then you see details of the services covered and a Total Example Cost. Finally, the coverage examples show the total Cost-Sharing.
The SBC is a great place to start for a quick review of your plan. For more details, look for your Benefit Book in BAM.