On April 6, 2016, the Department of Health and Human Services (HHS), the Department of Labor (DOL) and the Department of the Treasury (the Agencies) announced key enhancements to the Summary of Benefits and Coverage (SBC) template and Uniform Glossary that the Agencies issued on February 26, 2016. These final improvements include an additional coverage example and language and terms to improve consumers’ understanding of their health coverage.
Health plans and issuers must use this new final SBC template beginning on the first day of the first open enrollment period that begins on or after April 1, 2017. Click here for a recent Leavitt article about ACA FAQ 30, which the Agencies issued in early March to clarify the April 1, 2017 date. Click here for the cms.gov/cciio webpage that includes links to the new final version of the SBC, Uniform Glossary and other related documents and instructions. A list of all the documents is included below.
Background on SBCs
The Affordable Care Act requires health plans and health insurance issuers to provide a brief summary of what the plan covers and the cost sharing responsibility of the consumer, in order to help individuals make more informed choices among health plan options and better understand their coverage. In addition to the SBC, plans and issuers also are required to provide a comprehensive uniform glossary of commonly used health coverage and medical terms.
Improvements in the Finalized Version over Prior SBC Templates
The original SBC template included two coverage examples to demonstrate the cost-sharing amounts an enrolled individual might be responsible for in two common medical situations: diabetes care and childbirth. The updated template adds a new coverage example that addresses coverage for a foot fracture, so that a consumer understands what a plan covers in an emergency scenario.
Changes have also been made to the SBC to improve readability for consumers. 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 in the SBC. These improvements reflect input from consumer groups, the National Association of Insurance Commissioners, and other stakeholders.
The SBC is available for every Marketplace plan and most non-Marketplace plans.
Where to Access the Final Versions of the SBC and Related Documents
The following documents and links are included on the cms.gov/cciio website link listed earlier in this article. Below are direct links to each document.
- Summary of Benefits and Coverage (SBC) Template [PDF] [MS Word]
- Sample Completed SBC [PDF] [MS Word]
- Instructions for Completing the SBC: Group Health Plan Coverage
- Instructions for Completing the SBC: Individual Health Insurance Coverage
- Why This Matters language for “Yes” Answers
- Why This Matters language for “No” Answers
- Guide for Coverage Examples Calculations:
- Coverage Examples Narrative:
- Uniform Glossary of Coverage and Medical Terms
- List of Anchors for SBC Uniform Glossary Terms
- Coverage Examples Calculator Instructions
- Coverage Examples Calculator [XLSM] (updated April 2016)