Understanding Your Documents
 
 

Summary of Benefits and Coverage (SBC)

You have the right to an easy-to-understand summary about a health plan’s benefits and coverage, commonly known as an SBC. This information helps you make “apples-to-apples” comparisons when you’re looking at plans. 

The SBC shows how you and the plan share the cost for covered health care services, and also includes details - or “coverage examples” - which show you what the plan would cover in 2 common medical situations: diabetes care and childbirth. A glossary of terms used in health coverage and medical care is also included.

Keep in mind the SBC is only a summary. For detailed information about your plan’s coverage, log in to the secure portal to view your Benefit Document. 

Benefit Document / Evidence of Coverage (EOC) / Certificate of Insurance (COI)

Your Benefit Document (sometimes referred to as an Evidence of Coverage (EOC) or Certificate of Insurance (COI)) is a legally binding document provided by us that gives you a complete overview of your covered medical services. 

The Benefit Document explains your medical coverage, including covered benefits, exclusions, termination, continuation of coverage, and appeals. If there is a difference between the information in this Welcome Kit and your Benefit Document, please rely on your Benefit Document. 

You can find your Benefit Document on mytuftshealthplan.com. In the My Coverage (1) section, select My Benefits and look for the link under your plan name (2).

Explanation of Benefits (EOB)

What is an Explanation of Benefits (EOB)?

An EOB, or explanation of benefits, is not a bill. It's a report that provides you with useful information about how we processed claims from providers who rendered care for you. The EOB shows what charges were submitted to us, and what amount you owe to the provider, if any.

How to read your EOB

How to Find an EOB

Not all processed claims trigger an EOB. You receive an EOB only when we have processed claims that affect your plan's limits, such as deductibles, coinsurance, and out-of-pocket maximums. And because EOBs indicate any financial responsibility you may have for health care services you have received, EOBs help you check the accuracy of bills from your providers.

You can find the EOB for a claim, if one has been generated, on mytuftshealthplan.com. In the Claims section, find the claim in the summary list and select Details to view the Claims Details page (1).