Summary of Benefits and Coverage
Under health care reform, health insurers and self-funded employers must provide a uniform Summary of Benefits and Coverage (SBC) to people who apply for and enroll in health plans.
The final rule of the Patient Protection and Affordable Care Act, issued on February 9, 2012, applies to all documents created prior to March 31, 2017. These plan documents must 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
- Standard glossary of medical and insurance terms
Effective September 1, 2015, SBCs must also include the following “administrative” information:
- When a new SBC must be provided and availability of electronic versions
- Disclosures by issuers of qualified health plans
- Issuing responsibilities for plans including more than one insurer and 3rd party vendors
On April 6, 2016, the Department of Labor (DOL) issued final regulations on a new SBC template, instructions and related documents. These final regulations apply to all documents created on or after April 1, 2017.
- Calendar year plans must comply with the new requirements as of the first day of open enrollment on or after April 1, 2017
- Non-calendar year plans must comply with the new requirements as of the first day of the first plan year beginning on or after April 1, 2017
The general format of the new SBC template is similar to the current version. Some changes include:
- Removed cost-sharing definitions, i.e., copayment, coinsurance and allowed amount
- Added preauthorization language for an office visit, outpatient surgery and hospital stay
- Revised language on preventive care and wellness programs, “You may have to pay for services that aren’t preventive,” and “You may be able to reduce your costs”
- Added tier references to prescription drugs, i.e., generic, preferred, non-preferred and specialty
- Changes to examples of how the plan’s coverage works, including the breakdown of costs related to pregnancy care and the addition of a cost example for a simple fracture
- New information on minimum essential coverage, minimum value, and language access services
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.
- Read the SBC Fact Sheet
- See the Department of Labor SBC templates, instructions and related materials