Summary of Benefits and Coverage (SBC)

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This “simple” document must be provided to employees about half-a-dozen different times.

Overview

Section 2715 of the Public Health Service Act, as added by the ACA, generally requires all group health plans and health insurance issuers offering group health insurance coverage to provide applicants, enrollees, and policyholders or certificate holders with a summary of benefits and coverage that “accurately describes the benefits and coverage under the applicable plan or coverage.”

PHS Act section 2715 also calls for the “development of standards for the definitions of terms used in health insurance coverage.”

There are a total of 12 required content elements under the regulations, including uniform standard definitions of medical and health coverage terms, which will help consumers better understand their coverage; a description of the coverage including the cost sharing requirements such as deductibles, coinsurance, and copayments; and information regarding any exceptions, reductions, or limitations under the coverage. The final regulations also require inclusion of coverage examples, which illustrate benefits provided under the plan or coverage for common benefits scenarios.

Willful failure to provide the information required under this section can result in a $1,000 fine plus a separate fine for each individual or entity for whom there is a failure to provide an SBC.

Source: Summary of Benefits and Coverage and Uniform Glossary Final Regulations

Regulations and Guidance

Final Regulations: Summary of Benefits and Coverage and Uniform Glossary
This document contains final regulations regarding the summary of benefits and coverage and the uniform glossary for group health plans and health insurance coverage in the group and individual markets under the Patient Protection and Affordable Care Act. This document implements the disclosure requirements under section 2715 of the Public Health Service Act to help plans and individuals better understand their health coverage, as well as other coverage options. (02/14/2012)
Guidance for Compliance
Summary of Benefits and Coverage and Uniform Glossary–Templates,Instructions, and Related Materials; and Guidance for Compliance (2/14/2012)
Proposed Regulations
Summary of Benefits and Coverage and the Uniform Glossary; Proposed Rules (8/22/2011)
Solicitation of comments – Templates, Instructions, and Related Materials
Summary of Benefits and Coverage and Uniform Glossary–Templates, Instructions, and Related Materials Under the Public Health Service Act (8/22/2011)
Culturally and Linguistically Appropriate Services (CLAS) County Data
PHS Act section 2719 requires non-grandfathered group health plans and health insurance issuers offering non-grandfathered health insurance coverage to provide relevant notices in a culturally and linguistically appropriate manner. The regulations implementing section 2719 require these plans and issuers to make certain accommodations for notices sent to an address in a county meeting a threshold percentage of people who are literate only in the same non-English language. This threshold percentage is set at 10 percent or more of the population residing in the claimant’s county. This list includes all counties which meet or exceed the 10 percent threshold for the 2006-2010 ACS data and is applicable for 2012. This list will be updated annually.

Templates, Instructions, and Related Materials

Summary of Benefits and Coverage (SBC) Template | MS Word Format
Authorized for second year of applicability
Sample Completed SBC | MS Word Format
Authorized for the second year of applicability
Summary of Benefits and Coverage (SBC) Template | MS Word Format
Authorized for the first year of applicability
Sample Completed SBC | MS Word Format
Authorized for the first year of applicability
Instructions for Completing the SBC – Group Health Plan Coverage
PHS Act section 2715 generally requires all group health plans and health insurance issuers offering group health insurance coverage to provide applicants, enrollees, and policyholders or certificate holders with an accurate summary of benefits and coverage. This is the instruction guide for group coverage.
Instructions for Completing the SBC – Individual Health Insurance Coverage
PHS Act section 2715 generally requires all group health plans and health insurance issuers offering group health insurance coverage to provide applicants, enrollees, and policyholders or certificate holders with an accurate summary of benefits and coverage. This is the instruction guide for individual health insurance coverage.
Why This Matters language for “Yes” Answers
Many of the questions included on the Summary of Benefits and Coverage have “yes” or “no” answers. Also included is a “why this matters” section. This document provides language for the “why this matters” column for questions with “yes” answers.
Why This Matters language for “No” Answers
Many of the questions included on the Summary of Benefits and Coverage have “yes” or “no” answers. Also included is a “why this matters” section. This document provides language for the “why this matters” column for questions with “no” answers.
HHS Information For Simulating Coverage Examples
This webpage provides information needed to simulate coverage examples for the Summary of Benefits and Coverage.
HHS Coverage Example Calculator
Coverage scenarios cost sharing calculator tool developed by HHS for use when preparing examples on the Summary of Benefits and Coverage.
Uniform Glossary of Coverage and Medical Terms
This glossary contains many commonly used health coverage and medical terms.

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