1. What does SBC mean?
SBC is short for Summary of Benefits and Coverage. It is a document intended to help people understand their health coverage and compare health plans when shopping for coverage.
2. Why is the SBC being issued?
The federal government requires all healthcare insurers and group health plan sponsors to provide this document to plan participants at certain times beginning September 23, 2012.
Group health plan sponsors (Employers) must provide a copy of the SBC to each employee eligible for coverage under the plan. If more than one plan is offered to the group’s employees, only the SBC specific to the plan for which an employee is eligible must be provided to that employee. However, if an employee asks to see a different plan’s SBC, that SBC must also be provided so he or she can compare plans.
Fully insured groups: The insurance company will provide the SBC to both the group official and the employees at the required times, except during initial enrollment and open enrollment periods, when they will rely on the group official to provide it to employees.
Self-funded groups: The insurance company will provide the SBC to the group official, who is responsible for distributing it to employees at the required times.
3. What information is included in the SBC?
The SBC includes:
- A summary of the services covered by the plan
- A summary of the services not covered by the plan
- The copays and/or deductibles required by the plan, but not the premium
- Information about members’ rights to continue coverage
- Information about members’ appeal rights
- Examples of how the plan will pay for certain services
4. What do the coverage examples in the SBC show?
The federal government requires all insurance companies and group health plans to provide two examples of covered services under the plan. The two examples are having a baby and managing type 2 diabetes. The examples are not intended to show exact costs, because each person’s care will be different. Instead, the sample costs are based on national averages supplied by the Department of Health and Human Services. They are not specific to a certain geographic area or health plan. These examples should help compare coverage between plans. The “Patient Pays” box at the bottom of each example shows how each plan offers more or less coverage for these two conditions.
5. How often will a group health plan’s employees need to receive an SBC?
Beginning September 23, 2012, insurers and group health plan sponsors are required to provide the SBC to eligible employees and plan participants at these various times:
- When an employee is first eligible for coverage
- At renewal/open enrollment
- By the first day coverage starts, if the SBC changed from the version provided during annual open enrollment
- After a request for special enrollment, as defined by HIPAA
- If there is a mid-year change to the plan that affects the information in the SBC
- Upon request
6. Will there be a charge for providing the SBC?
There will not be a charge to the member for the SBC. The group will receive one copy of each plan’s SBC to a group official at no charge. Additional fees may apply if a group asks us to provide SBCs beyond what is required by the Affordable Care Act (ACA).
7. Can a member stop receiving the SBC?
No. Providing the SBC is required by the ACA.
8. What will happen if the SBC is not provided to employees/participants?
Group health plan sponsors and health insurance issuers that do not provide the SBC to its employees, participants or members may be subject to fines.