The Affordable Care Act
Under the Affordable Care Act, all health insurers and group health plans are required to provide consumers
with a Summary of Benefits and Coverage (SBC). The SBC is a summary of the benefits and health coverage
offered by a particular plan. The SBC is intended to provide clear, consistent, easy-to-understand descriptions
that may make it easier for people to understand their health insurance coverage and for consumers to shop
for and compare insurance plans.
The SBC is completed using a government designed template, so the SBC will be consistent across all health
insurance plans and will include:
What is covered by the plan
What is not covered by the plan
Cost-sharing provisions and exclusions
Coverage Examples
A web site and phone number for customer service and obtaining more information
The items in the SBC just represent an overview of coverage; they are not an exhaustive list of what is covered or
excluded. The full terms of coverage are located in the insurance policy.
Will the SBC be available in foreign languages?
The Affordable Care Act requires that the SBC “is presented in a culturally and linguistically appropriate
manner.” The regulations state that if at least 10% of the population living in a particular county is literate
only in the same non-English language, health insurance issuers or group health plans must provide:
Interpretive services and written translations of the SBC upon request in certain, specified non-English languages
English versions of the SBC that must disclose availability of language services in the relevant language
Who is impacted by this requirement?
The SBC requirement applies to health insurance issuers offering insurance in both the individual and group
markets. It also applies to group health plans, both fully insured and self-insured. The SBC is not required
for stand-alone retiree-only plans, stand-alone dental and vision plans, Health Savings Accounts and Flexible
Spending Arrangements (when they are excepted benefits).
When is the SBC provided?
It must be provided at certain specified times, which include:
Upon application
At enrollment
Annually at re-enrollment
Upon request (no more than 7 business days after the request)
At special enrollment (must be provided within 90 days after enrollment)
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Affordable Care Act Guide to the Summary of Benefits and Coverage for Employers
A request may come from an individual or dependent enrolled in an individual health insurance policy, from a participant
or beneficiary enrolled in a group health plan, or from non-members who are shopping for coverage, despite the fact
that they are not enrolled with us.
If a group health plan or health insurance issuer makes any changes to the terms of coverage, a
Notice of Material
Modification
must be provided no later than 60 days prior to the date the change becomes effective. This notice is
only required when the change in coverage is not included in the most recent SBC and when the change is outside
a renewal or reissuance of coverage.
A material modification may be:
An enhancement or reduction in benefits
A change in the plan or policy terms
A reduction in cost sharing
Coverage of previously excluded benefits
Stricter requirements for receipt of benefits
When does this provision go into effect?
The effective dates for this requirement are different depending on the situation.
For any enrollment through an open enrollment (OE) period, the SBC must be provided beginning on the first day
of the first OE that begins on or after September 23, 2012.
For any enrollment other than through an OE period, the SBC must be provided beginning on the first day of the
first plan year that begins on or after September 23, 2012.
Below are some typical scenarios to help explain when an SBC will be provided in the
group market.
Scenario Is SBC required? When do the SBC requirements
take effect?
Open Enrollment
Group has OE starting 10/1/12 Yes (during OE) During the plan’s OE period
Group has OE starting 9/1/12 No (not during this year’s OE) During the plan’s OE period after 9/23/12.
In this case, it would be 9/1/13.
Special Enrollee (Outside OE period)
Group has OE from 9/1/12 to
9/30/12 for effective date 1/1/13.
A new enrollee joins the plan
effective 10/1/12
No Starting on the first day of the first
plan year after 9/23/12. In this case,
it would be 1/1/13.
Group has OE from 10/1/12 to
10/30/12 with a calendar year
plan that begins 1/1/13. A new
enrollee joins the plan effective
11/10/12.
No Starting on the first day of the plan year
after 9/23/12. In this case it would be
1/1/13. For new enrollees who join prior
to 1/1/13, an SBC would not be required.
Any enrollee who joins on or after 1/1/13
would receive an SBC within 90 days of
their enrollment.
Upon Request
On or after 9/23/12, a plan
administrator requests an SBC
Yes Within 7 business days
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Who is responsible for providing the SBC?
The legal obligations are not the same for fully insured and self-insured plans. It is important to know what is
expected of you and your health insurance plan.
Fully Insured Groups
By law, the insurer and the employer each have the independent responsibility of creating and distributing the SBC
for fully insured health plans.
Our approach to fully insured groups:
We will create the SBC for all fully insured plans and ensure that information is accurate.
We will only create the SBC for medical benefits that we administer. The employer is responsible for
gathering information for benefits that we do not administer. The employer might then choose to
synthesize this information into a single SBC or provide multiple partial SBCs, where permitted by law.
The group administrator will access the SBC using our SBC tool and will distribute it to members.
A link with access instructions to our SBC site will be distributed to all group administrators. Group administrators
will have the ability to log on to the site to access their plan’s SBC.
For new groups sold after 10/01/12, the group administrator can access the SBC tool for that standard plan and
distribute to the group.
We will provide translation services and provide the SBC in foreign languages in accordance with the
regulation. The employer must request the SBC in a foreign language. We will not automatically provide SBCs
in foreign languages.
Self-Insured Groups
The law makes it the employer’s responsibility to create and distribute the SBC for self-insured plans. The health
insurer has no legal obligation to do so.
Our approach to self-insured groups:
We will create the SBC for self-insured groups that request our services.
The Account Executive (AE) and/or the plan administrator will validate and approve the information in the SBC.
The AE for the group will access the SBC using our SBC tool.
A link with access instructions to our SBC site will be distributed to all group administrators. Group administrators
will have the ability to log on to the site to access their plan’s SBC.
The AE will email the completed SBC to the group, which will distribute it to members.
We will provide translation services and provide the SBC in foreign languages in accordance with the
regulation. We will not automatically provide SBCs in foreign languages.
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
56301.0812
Affordable Care Act
Guide to the Summary of Benefits and Coverage for Employers
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