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The Affordable Care Act (ACA) requires that issuers and health plans provide a Summary of Benefits and Coverage (SBC), including a description of what the health plan covers and the cost sharing responsibility of the consumer, in order to help individuals make more informed choices among health plan options and to better understand their coverage. Self-funded health plans and health insurance companies are also required to provide a comprehensive uniform glossary of commonly used health coverage and medical terms.
The federal agencies overseeing the ACA have recently finalized changes to the existing SBC template in order to improve the readability for consumers, and also to expand the amount of information that the consumer receives from this one document. The new templates include more information about cost sharing, such as enhanced language to explain deductibles and a requirement that plans address individual and overall out-of-pocket limits.
All SBC’s include coverage examples that demonstrate the cost sharing amounts an individual might be responsible for in three common medical situations. Currently, the SBC contains two coverage examples, which address diabetes care and childbirth. The new template offers a third coverage example which addresses coverage for a foot fracture so that a consumer understands the services and expenses that a plan will cover in an emergency scenario.
Use of the new template will be required for plans and insurance policies with plan years beginning on or after April 1, 2017. This also means that the new template should be used for SBC’s that will be distributed for any open enrollment period preceding the April 1, 2017 plan year.
There are no changes to the existing SBC distribution requirements. SBC’s are required to be distributed, as follows:
If you are a MedBen client, please make sure to provide us with enough time to update your SBC and send it to you for timely distribution. It is important that you inform us in advance if you will be making changes to your plan documents which require changes to your SBC.
Should you have any questions about SBCs, please contact Sierra See, J.D., in MedBen’s Compliance Department at email@example.com.