What the benefits summary is
When you join an employer or approach open enrollment, you typically receive an overview of what is offered: medical, dental, vision, life insurance, disability, retirement and other programs. This overview goes by several names, such as a benefits guide, enrollment guide or benefits summary. It is meant to help you choose, not to be the legal contract.
That last point matters. The summary is usually a simplified version of longer documents. If there is ever a conflict, the plan documents generally control, and the summary will often say so near the front or back. This article is general information, not insurance, legal or financial advice, and layouts differ widely.
A sensible reading order
Reading it from start to finish can be tiring. Consider this order:
- Dates and deadlines. Find the enrollment window, the date coverage begins and any deadline for supplying documents. A missed deadline can mean waiting a year.
- Eligibility. Check who can enroll: full-time or part-time employees, spouses, children and domestic partners. Look for any waiting period before coverage starts.
- Plan comparison chart. This is usually the heart of the document.
- Cost tables. See what you would pay per paycheck for each tier.
- Other benefits. Read about dental, vision, accounts, disability, life insurance and extras.
- Contacts and next steps. Note whom to call and how to enroll.
Reading the plan comparison chart
Plan charts put options side by side. The items you will commonly find include:
- Deductible. What you pay before the plan begins to share costs for many services. The chart may show separate individual and family amounts.
- Copays and coinsurance. Fixed fees or percentages for visits and services.
- Out-of-pocket maximum. The most you would pay in a plan year for covered, in-network care, in general. Premiums usually do not count toward it.
- Network type. Whether the plan is an HMO, PPO or another type, which affects which providers you can use without paying more or needing referrals.
- Prescription tiers. Costs often vary by drug category.
- Preventive care. Often shown as covered at no or low charge, subject to plan rules.
Notice what the chart does not show. It cannot list every service, and a row reading “specialist visit: $40” may leave out when prior authorization or a referral is needed. For anything you are counting on, such as a planned procedure, ask for the details.
Reading the cost tables
Cost tables show the payroll deduction for each plan and tier. Look for:
- the pay period used (weekly, biweekly, semi-monthly or monthly), since comparing a monthly figure to a biweekly one can mislead
- whether amounts are before or after tax
- whether the employer contribution is displayed
- surcharges, such as tobacco or spousal charges, or discounts for wellness activities
A hypothetical check: if a table lists $120 per biweekly paycheck and you are paid 26 times a year, the annual cost is $3,120. Compare that with plans on the same basis, and weigh it against the deductible and other costs you might face. Comparing more than the premium is the idea behind weighing premiums and costs together.
Looking for the fine print
Common items worth finding:
- exclusions and limits, such as caps on visits for therapy or annual dollar maximums on dental
- how out-of-network care is handled
- what happens if you change jobs or lose eligibility
- whether any plan is a high-deductible design that works with an account
- notices about legal rights, which often appear near the end
What a summary usually leaves out
- Whether your specific doctor or hospital is in the network. Use the plan’s provider directory, and confirm with the provider’s office.
- Whether your regular medication is covered, and at what tier. Check the plan’s drug list.
- The detailed definitions and rules found in the full plan documents. Many summaries link to or name these, sometimes under policy documents or a summary of benefits and coverage.
Gaps to fill with questions
Write down anything unclear and ask your HR or benefits team. Useful questions include: Which plan did most employees with similar needs choose? (They may not be able to answer.) When does coverage begin? Can I change my choice mid-year? What happens if I go on leave?
Take your time before the deadline. The summary is a starting point, and the details can differ from one employer to the next.