Summary of Benefits and Coverage (SBC)

Health Insurers and Group Health plans are required to provide SBCs under the Affordable Care Act. Requirements and Helpful Templates can be found HERE.

An SBC is an overview of a specific health plan including its costs, its benefits, the health care service it covers, and its related plan details. SBCs should also explain any significant limits and exceptions to coverage in easy-to-understand language.

SBCs are required to be supplied to Members who are enrolling in a new plan. Members who are currently enrolled are required to be given the new SBC on the first day of open enrollment. Anyone who is newly eligible for a plan should get the SBC on the first date of the plan year. Additionally, SBCs should be provided when there are coverage changes within a plan year or anytime a Member requests one.

Information required to be included on an SBC

Health Insurance documents can be very complicated. In addition to very specific requirements about how an SBC is design, right down to font sizes, there are many areas that have specific things that have to be included per regulations. Some of these include:

  • Uniform definitions of standard terms for insurance options and medical treatments.
  • A description of each category of benefits covered, including cost sharing.
  • Exceptions, limitations and reductions of policy coverage.
  • Cost-sharing provisions, including deductible, co-insurance and co-payments that need covered by the Member..
  • Policy renewal and continuation of coverage options.
  • Examples of how the policy covers different medical events
  • For policies in effect beginning on or after January 1, 2014, include a statement about whether the plan provides minimum essential coverage. Also state whether the plan meets the all requirements concerning the total share of allowable costs.
  • State that the SBC is a summary document. Refers Members to the original policy or contract for actual coverage details.
  • Provide contact information for policy questions.
  • Provide access to a list of network providers if applicable.
  • Provided access to a formulary for prescription drug coverage if applicable.
  • Provide a web address to access a uniform glossary of terms or a phone number to request a hard copy.

Summary of Benefits and Coverage FAQ

Of course! Our team of experts, both in health insurance documents and production, can help set up the appropriate templates of any documents you need.

Yes. The US Department of Labor provides SBC instructions and templates on their website.

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