Health care reform legislation requires health plans and health insurance issuers to provide a summary of benefits and coverage (SBC) to applicants and enrollees in Business Benefits Group’s health plan.
What is the Summary of Benefits and Coverage?
The SBC is a concise document providing simple and consistent information about health plan benefits and coverage. It must be provided free of charge. Its purpose is to help you better understand the coverage you have and to make easy comparisons of different options when selecting new coverage.
When will I receive my summary of benefits and coverage?
You will receive an SBC upon application for health coverage, or, in some cases, by the first day of coverage.
You will also receive an SBC when your health care issuer renews or reissues your policy, such as after open enrollment.
You can also request an SBC at any time. SBCs that are provided upon application (by issuers) or upon request (by either plans or issuers) must be provided as soon as practicable, but no later than seven days after receipt of the application or request.
What is all included in the SBC?
The SBC must contain:
- Uniform definitions of standard insurance and medical terms
- A description of coverage, including cost-sharing for specified categories benefits
- Exceptions, reductions and limitations on coverage
- Cost-sharing provisions, including deductible, coinsurance and copayment obligations
- Renewability and continuation of coverage provisions
- Specified coverage examples that illustrate benefits provided under the plan or coverage for common benefits scenarios (including pregnancy and serious or chronic medical conditions)
- A statement that the outline is a summary of the policy and that the coverage document itself should be consulted for contractual provisions
- A contact number for consumers and a web address where a copy of the actual coverage policy or certificate of coverage can be reviewed and obtained
- For plans and issuers with one or more provider networks, an Internet address (or similar contact information) for obtaining a list of the network providers
- For plans and issuers with a prescription drug formulary, an Internet address (or similar contact information) for obtaining information about the prescription drug coverage
- An Internet address for obtaining the uniform glossary, a contact phone number to obtain a paper copy of the uniform glossary and a disclosure that paper copies are available
The SBC is not required to include premium or cost of coverage information.
Beginning in 2014, the SBC must include a statement of whether the plan provides minimum essential coverage and ensures that the plan’s share of total allowed costs meets applicable requirements.
What do I have to do?
As long as you are properly enrolled, it is the plan issuer’s responsibility to get you a copy of the SBC.
What are my rights?
If your employer offers you an electronic version of your SBC, you are legally entitled to request and be offered a paper copy.