Free SBC Comparison Tool for Benefits Brokers

What is an SBC (Summary of Benefits and Coverage)?

The Summary of Benefits and Coverage (SBC) is a standardized, ACA-required document that explains health plan benefits in plain language. All carriers must provide SBCs using the same format, making it easier to compare plans across different insurers.

SBCs are typically 4-8 pages and include:

• Plan overview: Key features and benefit highlights
• Important questions: Standardized cost and coverage information
• Common medical events: Cost examples for specific scenarios (having a baby, managing diabetes, etc.)
• Coverage examples: What the plan pays for typical situations
• Exclusions: Services not covered by the plan
• Additional information: Grievance procedures and language assistance

Why Brokers Need SBC Comparison Tools

While SBCs use standardized formats, manually comparing multiple carrier documents is still time-consuming:

• Multiple documents: Several plan options can span many source pages
• Detail-oriented: Small differences in copays or coinsurance are easy to miss
• Time-consuming: Manual comparison repeats data entry and formatting work
• Error-prone: Easy to misread or mistype benefit details
• Client expectation: HR teams expect side-by-side comparison summaries
• Proposal critical: Accurate comparisons are essential for recommendations

How SBC Comparison Tools Work

Manual Method (Traditional Approach)

Work: manual transcription, comparison, and proofing

1. Print or open 3-5 SBC documents from different carriers
2. Create Excel spreadsheet with benefit categories in rows
3. Manually type deductibles, copays, and coinsurance from each SBC
4. Transcribe out-of-pocket maximums and premium information
5. Format comparison table for client presentation
6. Proofread for typos and transcription errors

Automated Method (BART)

Work: source review followed by a side-by-side comparison

1. Upload the SBC PDFs you need for the case
2. Review extracted benefit data alongside its source document
3. Review extracted data in side-by-side format
4. Export comparison as formatted PDF or Excel

What Information is in an SBC?

Page 1-2: Key Benefit Information

• Overall deductible (individual and family)
• Are there services covered before you meet your deductible? (Yes/No)
• Are there other deductibles for specific services? (Details)
• 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? (Yes/No)
• Do you need a referral to see a specialist? (Yes/No)

Page 3-5: Common Medical Events

SBCs detail costs for these standardized scenarios:

• If you visit a health care provider: Primary care visit, specialist visit, other practitioner, preventive care/screening
• If you have a test: Diagnostic test (x-ray, blood work), imaging (CT/PET/MRI), generic drugs, preferred brand drugs, non-preferred brand drugs, specialty drugs
• If you need immediate medical attention: Emergency room care, emergency medical transportation, urgent care
• If you have a hospital stay: Facility fee, physician/surgeon fee
• If you need mental health, behavioral health, or substance abuse services: Outpatient services, inpatient services
• If you are pregnant: Office visits, childbirth/delivery professional services, childbirth/delivery facility services
• If you need help recovering or have other special health needs: Home health care, rehabilitation services, skilled nursing care, durable medical equipment, hospice services
• If your child needs dental or eye care: Children's eye exam, children's glasses, children's dental check-up

Page 6-8: Coverage Examples and Exclusions

• Coverage example: Having a normal baby
• Coverage example: Managing Type 2 diabetes (routine maintenance)
• Coverage example: Simple fracture (emergency treatment)
• List of excluded services and other covered services
• Language assistance information

Key Differences Between SBCs and Other Documents

SBC vs. Plan Benefit Summary

• SBC: ACA-mandated, standardized format, consumer-focused language
• Benefit Summary: Carrier-created, flexible format, may include more details

SBC vs. Evidence of Coverage (EOC)

• SBC: 4-8 pages, high-level summary, plain language
• EOC: 50-200+ pages, comprehensive legal document, technical language

SBC vs. Schedule of Benefits

• SBC: Covers all benefit types using standardized categories
• Schedule: Detailed listing of specific procedures and coverage levels

Common SBC Comparison Challenges

1. Inconsistent Terminology

Despite standardization, carriers use slight variations: "Primary Care Physician" vs. "PCP Visit" vs. "Office Visit - Primary Care"

2. In-Network vs. Out-of-Network

SBCs show both in-network and out-of-network costs. Brokers must ensure they're comparing equivalent network tiers (PPO in-network to PPO in-network, not mixing tiers).

3. Embedded vs. Non-Embedded Deductibles

Family deductibles may be embedded (each family member has individual limit) or non-embedded (family must meet full family deductible). SBCs don't always make this distinction clear.

4. Coinsurance After Deductible

Some benefits show copays, others show "XX% coinsurance after deductible." Comparing copay plans to coinsurance plans requires careful analysis.

5. Rx Coverage Tiers

Prescription drug coverage varies: generic, preferred brand, non-preferred brand, specialty. Some carriers have 3 tiers, others have 5+. SBCs may not detail all tiers.

How to Compare SBCs Manually

Step 1: Create Comparison Framework

Set up Excel spreadsheet with benefit categories as rows (deductibles, copays, coinsurance, OOP max) and plans as columns.

Step 2: Extract Key Benefits

Start with pages 1-2 "Important Questions" section. Record:

• Overall deductible (individual and family)
• Out-of-pocket maximum (individual and family)
• Coinsurance percentages

Step 3: Document Common Medical Events

From pages 3-5, transcribe costs for:

• Primary care visit
• Specialist visit
• Emergency room
• Inpatient hospital
• Generic drugs, preferred brand drugs

Step 4: Note Exclusions and Limitations

Record any unusual exclusions or coverage limitations that differ from other plans.

Step 5: Analyze Coverage Examples

Review the three standardized coverage examples (baby delivery, diabetes management, simple fracture) to understand total cost differences.

Step 6: Format for Presentation

Clean up formatting, add conditional formatting to highlight key differences, and prepare for client review.

How BART Automates SBC Comparison

BART's SBC comparison workflow keeps source material and plan review in one case:

• Upload case SBCs: Bring the PDFs you need into one reviewable case
• Extraction for review: Organize benefit details from the standardized SBC format
• Source verification: Confirm deductibles, copays, coinsurance, and out-of-pocket maximums against the original documents
• Side-by-side display: Compare approved plan values in a clear table
• Highlight differences: Visual indicators show where plans differ significantly
• Include premiums: Add premium data to show total cost picture
• Export options: Download as PDF, Excel, or integrated into full proposal
• Source review: Confirm important plan values before you deliver the comparison

SBC Comparison Best Practices

• Use most recent SBCs: Carriers update SBCs annually; ensure you have current versions
• Compare in-network to in-network: Don't mix network tiers in comparisons
• Include premium costs: SBCs don't show premiums; add separately for complete picture
• Highlight key differences: Use color coding to draw attention to significant variations
• Focus on client priorities: Emphasize benefits most relevant to employee population
• Explain coinsurance: Many employees don't understand "20% after deductible"
• Show total cost examples: Use SBC coverage examples to illustrate real-world costs
• Keep original SBCs: Provide full SBC documents in addition to comparison summary

Understanding SBC Medical Cost Examples

SBCs include three standardized cost examples. Here's how to use them:

Example 1: Having a Baby (Normal Delivery)

Shows costs for prenatal care, delivery, and postnatal care. Useful for comparing maternity coverage across plans.

What to look for: Total costs, patient responsibility, whether delivery copay is separate from hospital stay

Example 2: Managing Type 2 Diabetes (Routine Maintenance)

Shows ongoing care costs including doctor visits, prescriptions, and routine tests. Useful for employees with chronic conditions.

What to look for: Rx costs, routine visit copays, lab work coverage

Example 3: Simple Fracture (Emergency Treatment)

Shows emergency room visit, x-rays, and follow-up care. Useful for understanding acute care costs.

What to look for: ER copay vs. coinsurance, specialist follow-up costs, imaging charges

SBC Compliance Requirements

Carriers and employers must follow these SBC rules:

• Distribution timing: Must provide SBC at enrollment, upon request, and with material plan changes
• Format requirements: Must use standard SBC template and format
• Language: Must be provided in culturally and linguistically appropriate manner
• Accessibility: Must be available in paper and electronic formats
• Coverage effective dates: Must reflect current plan year benefits

Frequently Asked Questions

What is an SBC in health insurance?

An SBC (Summary of Benefits and Coverage) is a standardized, ACA-required document that explains health plan benefits in plain language using the same format across all carriers. It's designed to make plan comparison easier for consumers.

How do I compare SBC documents side-by-side?

Bring the SBCs for a case into BART, review extracted plan details alongside their source documents, then compare the confirmed values side by side.

Are all SBCs the same format?

Yes, the ACA requires all carriers to use the same standardized SBC template and format. However, there are slight variations in how carriers present some information, which can still make comparison challenging.

Where can I get SBC documents?

Carriers must provide SBCs upon request. You can get them from carrier representatives, download them from carrier websites, or request them during the RFP/quote process.

Does BART work with all carrier SBCs?

BART brings SBC documents into a reviewable case so brokers can compare plan details and confirm important values against the source files.

Can I compare SBCs from different states?

SBC formats are standardized, but plan designs and presentation can vary. Review the source documents included in your case before finalizing a recommendation.

Get Started with Automated SBC Comparison

Bring carrier SBCs into one case, review the extracted details against their sources, and prepare a clearer side-by-side comparison for the client conversation.