Summary of Benefits and Coverage: How to Read and Compare

What the federally required Summary of Benefits and Coverage tells you, section by section, and how to use it to compare health plans.

iHealthBenefit · Last reviewed October 26, 2026 · 6 min read

Every health plan sold in the United States comes with a short, standardized document that most people never read: the Summary of Benefits and Coverage, or SBC. It is one of the most useful tools you have for comparing plans, because every insurer and job-based plan has to fill out the same federal template.

HealthCare.gov describes the SBC as an easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between plans. This guide explains when you get one, what each section tells you, how to use the coverage examples, and what the SBC leaves out.

This is general information, not insurance, legal or medical advice. The SBC is a summary; your plan's full policy or plan documents control your coverage.

Who must give you an SBC, and when

Under the federal rule at 45 CFR 147.200, group health plans and health insurance issuers must provide an SBC for each benefit package without charge. HealthCare.gov adds that you can get one for all individual and job-based plans, including grandfathered plans.

The regulation sets out when you should receive it, including:

When you apply for coverage, as part of enrollment materials or soon after an application.
At renewal. If renewal is automatic, the SBC must arrive no later than 30 days before the new plan or policy year.
On request. A plan or issuer must provide it as soon as practicable, and no later than seven business days after you ask.
Before mid-year changes. If a plan makes a material change that would affect the SBC outside of renewal, it must notify enrollees no later than 60 days before the change takes effect.

If you shop on HealthCare.gov, there is a link to the SBC on each plan's page when you preview plans and prices. For job-based coverage, your HR or benefits office should have one for each option.

Why every SBC looks the same

The regulation requires a uniform format, terminology understandable by the average enrollee, no more than four double-sided pages and no print smaller than 12-point font. Plans must also make a Uniform Glossary of coverage and medical terms available, on paper or electronically, within seven business days of a request. HealthCare.gov notes that you may be able to get the SBC and glossary in a language other than English on request.

Because the order and wording are standardized, you can lay two SBCs side by side and read across.

Page one: the Important Questions

The first section is a short table of questions with the plan's answers and a "Why This Matters" column of standard explanations. In the Department of Labor's current template and sample, the questions include:

What is the overall deductible?
Are there services covered before you meet your deductible?
Are there other deductibles for specific services?
What is the out-of-pocket limit for this plan?
What is not included in the out-of-pocket limit?
Will you pay less if you use a network provider?
Do you need a referral to see a specialist?

These seven answers tell you a great deal. Separate drug deductibles, a high out-of-network limit or a referral requirement can change how a plan works for you more than the premium does. The SBC itself doesn't show the premium; the sample notes that cost information is provided separately.

The cost-sharing chart

Next comes a chart organized by "Common Medical Event" — visiting a provider's office, having a test, needing drugs, outpatient surgery, emergency care, a hospital stay, mental health and substance use services, pregnancy, recovery and special health needs, and children's dental or eye care.

For each service, the chart shows what you will pay with a network provider and with an out-of-network provider, and a "Limitations, Exceptions, and Other Important Information" column. Read that third column carefully. In the Department of Labor's sample, it flags services that require preauthorization and warns that benefits could be reduced if you don't get it, along with visit limits on services such as home health care and rehabilitation.

Exclusions, rights and coverage standards

After the chart, the SBC lists services the plan generally does not cover and other covered services that may have limits. It then explains your rights to continue coverage, where to get help with grievances and appeals, and answers two coverage questions:

Does this plan provide Minimum Essential Coverage?
Does this plan meet the Minimum Value Standards?

Those answers matter for Marketplace savings. The sample SBC explains that if you're eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit, and if a job-based plan doesn't meet Minimum Value Standards, you may be eligible for one.

Coverage examples: comparing plans on the same situations

The last section shows how the plan might handle sample medical situations. The Department of Labor's template for plan years beginning on or after January 1, 2021, uses three: "Peg is Having a Baby" (prenatal care and a hospital delivery), "Managing Joe's Type 2 Diabetes" (a year of routine care for a well-controlled condition) and "Mia's Simple Fracture" (an emergency room visit and follow-up care).

According to the government's SBC instructions, HHS supplies standardized data for the total cost of each example, and amounts are rounded to reinforce that they are estimates. Because the total example cost is the same for every plan, the differences in what the patient would pay come from the plan's design. The SBC says it plainly: this is not a cost estimator, and your actual costs will be different. The examples are based on self-only coverage.

How to use SBCs to compare plans

Get the SBC for every plan you're considering, plus each plan's premium.
Compare page one: deductibles, out-of-pocket limits, network rules and referral requirements.
Find the rows for care you actually expect, such as prescriptions, specialist visits or therapy, and compare both columns.
Read the limitations column and the excluded-services list for anything you rely on.
Use the coverage examples as a rough test of how each plan handles a big event.
Check that the plan provides Minimum Essential Coverage.

For job-based plans, the Department of Labor notes that the Summary Plan Description gives a more detailed overview of how the plan works and how to file a claim.

A scam check

HealthCare.gov advises getting coverage information from official sources and comparing plans carefully, and warns that the Marketplace and your state will never ask for payment to keep or qualify for coverage. Asking for an SBC is a reasonable step with any plan you're offered. If a seller can't or won't provide one, or the SBC says the plan doesn't provide Minimum Essential Coverage, stop and find out exactly what you're buying.

Where to get personal help

Ask your insurer or plan for an SBC or the Uniform Glossary at any time. For Marketplace questions, call the Marketplace Call Center at 1-800-318-2596. For job-based plans covered by federal benefits law, the Department of Labor's Employee Benefits Security Administration can help at 1-866-444-3272. Your state insurance department, listed in the NAIC directory, handles complaints about insurers.

Key takeaways

Insurers and job-based plans must give you an SBC free, including within seven business days of a request.
Every SBC uses the same federal template, so you can compare plans line by line.
Page one answers the key questions on deductibles, out-of-pocket limits, networks and referrals; premiums are shown separately.
The limitations column and exclusions list reveal preauthorization rules, visit limits and services not covered.
Coverage examples use the same standardized costs for every plan, but they are not cost estimates.

Sources

Our articles are general information, not medical, insurance, tax or legal advice, and we don't sell insurance or recommend specific plans or companies.

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