The Summary of Benefits and Coverage
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/Surgical 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 if 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:
- Having a Baby
- Managing Type II Diabetes
- Simple Fracture
These examples are based on presumptions of what services a person may receive over a year of each scenario. The numbers are industry based using government guidelines and do not reflect the actual cost of the scenario.
Versions for each NYSHIP HMO
The New York State Health Insurance Program (NYSHIP) offers eligible employees the option of choosing either The Empire Plan or a NYSHIP HMO for health insurance coverage. Click the plan names below to view a Summary of Benefits and Coverage for each option. To be eligible for coverage under a NYSHIP HMO, you must live or work in the HMO’s service area. Click here for a table of the counties each HMO serves in 2018.
We strongly encourage you to review other plan material before making a decision about the coverage you and your family will have for the next year. Refer to Choices for 2019 and other plan material for more detailed information.
Click on the link below to access the Summary of Benefits and Coverage for the following:
Questions and Answers
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 Empire Plan or the Uniform Glossary, call 1-877-7-NYSHIP (1-877-769-7447) and select the Medical/Surgical Program. If you need a paper copy of the Summary of Benefits and Coverage or the Uniform Glossary for a NYSHIP HMO, please contact the HMO.
Q. Should I use the Summary of Benefits and Coverage to decide which NYSHIP 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 Choices for 2019 for more information about The Empire Plan and NYSHIP HMOs 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 Certificate of Coverage, 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 experience one of these events?
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.