SBC - Deductible, Out-of-Pocket Limits, Networks, and Referrals
The SBC explains the deductibles for individuals and families, annual out-of-pocket limits, whether a provider network is used, and if certain services require referrals.
This is the standard format for all SBCs up until April 1, 2017. Please refer to the SBC in question for details specific to that plan. The layout may differ but the same information will exist.
On this page, we can:
- Determine the carrier, plan name, and plan type.
- Identify Individual and Family Deductibles (In-Network and Out-of-Network, service-specific, etc.).
- Learn about Individual and Family Out-of-Pocket Limits (In-Network and Out-of-Network).
- Confirm the limit on how much the carrier will pay for services in a year, if any.
- Determine if referrals are required to see specific doctors.
- Learn whether or not there are services this plan doesn't cover (usually this is a yes).
- Be made aware of important Limitations and Exceptions, like visit limits or preauthorization/precertification requirements.
Key Terms:
- Deductible
- Out-of-Pocket Limit
- In-Network and Out-of-Network
- Referrals (most commonly required in HMO plans and POS plans)