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 not required until made final with an effective date, would make the following "content" 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
- Allow but not require the inclusion of premium information
Additional requirements issued in June 2015 include “administrative” requirements such as:
- When a new SBC must be provided
- Availability of electronic versions
- Disclosures by issuers of qualified health plans
- Issuing responsibilities for plans including more than one insurer
- Responsible entities and their role in monitoring for compliance when designating to a 3rd party
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: