Revisions to Health Care Reform’s Summary of Benefits and Coverage

Group health plans are required to provide a Summary of Benefits and Coverage (“SBC”).  They were to have been required by March 23, 2012.  However, final rules now require the SBC to be distributed to employees for plan years that begin on or after September 23, 2012.  For example, if a plan year begins on January 1, 2013 and open enrollment is from October 1-November 1, the SBC must be available by October 1.

The SBC will have specific important questions enrollees may have, the answer, and explanations about why this matters.  Another section will outline common medical events, services which may be needed related to that event, costs for each service and any limitations/exceptions. 

Information about two specific situations must be included:  having a baby and managing Type 2 diabetes.  For each example, employers will need to use a government provided number for the amount owed to the providers.  The company then can fill in how much the employee and the plan would pay.  Other sample care costs, such as initial office visits, radiology, lab tests and hospital charges, must be added.  At the bottom of each example, under the heading “You Pay,” dollar figures would have to be provided on deductibles, copayments, coinsurance, and limits or exclusions. The requirement to include a third example, the cost of treating breast cancer, was dropped. 

The new regulations also make clear that new employees do not have to receive paper SBCs for every plan into which they may be eligible to enroll.  Instead they may be viewed (or downloaded) electronically.  For existing employees, the SBC will only need to be provided for the plan s/he is in.  However, an electronic link must be given to view other available plans.  Employees can request paper copies.

Although many insurers plan to provide SBC brochures, the Department of Labor has provided a template for employers to generate their own SBCs.  It is available at www.dol.gov/ebsa/pdf/SBCtemplate.pdf.

From Business Insurance, August 22, 2011 issue, pp. 4 and 21, and February 13, 2012 issue, pp. 4 and 18.