Summary of Benefits and Coverage
Under health care reform, health insurers and self-funded employers must provide a uniform Summary of Benefits and Coverage to people who apply for and enroll in health plans.
The final rule of the Patient Protection and Affordable Care Act, which was issued on February 9, 2012, requires that plan documents include a:
- Four-page overview of plan benefits, cost sharing and limitations
- Required set of examples of how the plan works
- Phone number and internet address for obtaining copies of plan documents
A standard glossary of medical and insurance terms must also be available.
Proposed regulations issued in December 2014 and effective September 1, 2015 would make the following changes:
- Shorten the SBC template to two-and-a-half double-sided pages
- Add a third cost example for a simple foot fracture treated in an emergency room
- Add definitions of new medical and health care reform terms to the glossary
- Require information about minimum essential coverage and minimum value to be included in the SBC rather than provided in a separate cover letter
- Allow but not require the inclusion of premium information
The penalty for "willful" non-compliance is $1,000 for each plan enrollee.
U.S.-issued expatriate plans are exempt from the requirement to provide SBCs.
We believe that it is in everyone's interest to ensure that plan participants understand the terms of their coverage. Accordingly, Cigna strongly supports the idea of making comprehensive and understandable coverage explanations available to plan participants.
- Read the SBC Fact Sheet
- Read our SBC FAQs
- Read the DOL SBC FAQs
- Access the DOL Template
- View a DOL Completed Sample SBC
Read the most recent Summary of Benefits and Coverage guidance:
More on Reform
INDIVIDUAL MANDATE IN REFORM
Under the health care reform law, all people must have minimum essential coverage beginning January 1, 2014.
EMPLOYER MANDATE IN REFORM
Businesses must offer affordable medical insurance that provides “minimum value” to employees and their dependents.
ESSENTIAL HEALTH BENEFITS
These new standards are required for individual and small group plans and may also affect large group plans.