Understanding 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.
Contents of the SBCs
The SBC 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.
Terms defined in the Uniform Glossary
Some words on the SBC are shown in bold and underlined. These terms are defined in the Uniform Glossary, a non-customized companion document to the SBC. 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.
Summary of Benefits and Coverage
Always refer to other plan material, such as your SEHP At A Glance, for more information about SEHP if you are making a decision about your family's coverage.
2026 SBCs
Frequently Asked Questions
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 plan material.
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 SEHP At A Glance for more information about The Empire Plan if you are making a decision about your family's coverage.
It's unlikely that you would pay the same amount listed in the "you pay" cell of the SBC. 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.
Yes, if you need a paper copy of the SBC for SEHP or the Uniform Glossary, call 1-877-769-7447 and select the Medical/Surgical Program.