Under the Affordable Care Act, health insurers and self-funded employers must provide a uniform Summary of Benefits and Coverage (SBC) to people who apply for and enroll in health plans. These plan documents must include a:
They must explain: when a new SBC must be provided, and how to access electronic versions
U.S.-issued expatriate plans are exempt from the requirement to provide SBCs.
SBC templates are occasionally updated by the Department of Labor. It is important to adhere to the standards for every individual plan year. The most recent update, to be used with plans beginning on or after January 1, 2021, eliminates information about the penalty for not having Minimum Essential Coverage.
The purpose of the Summary of Benefits and Coverage (SBC) is to provide individuals with standard information so they can compare medical plans as they make decisions about which plan to choose.
Effective September 23, 2012, health insurers and self-insured group health plans must provide an SBC at these times:
What information must be included in an SBC
An SBC must be created by inserting plan details into predetermined rows and columns using the exact wording, format and layout provided.
Links to SBC templates, instructions and related materials are available at https://www.dol.gov/agencies/ebsa.
While the documents have changed slightly since 2012, the general format of the current template is similar to the original version.
Overview of SBC requirements
General Format Four-page benefit summaryFour-pages (two-sided, eight pages maximum, 12-point font, in color or grayscale); can be included in another document, but must be placed prominently at the beginning.
Coverage examplesEstimated customer costs for three medical scenarios – having a baby, managing type 2 diabetes, and emergency room treatment for a simple fracture. The estimates are based on national average costs and in-network benefit levels under each plan.
Website and phone number A prominently displayed website and phone number where individuals can get additional information.Definitions of common medical and insurance terms. The glossary must be provided on request and is posted on www.healthcare.gov.
Minimum Essential Coverage/Minimum Value StandardInformation on whether the plan meets Minimum Essential Coverage and/or Minimum Value Standard requirements must be included.
60-day notice for material modifications during the plan year
If any material change is made to a plan during the plan year that is not reflected in the most recent SBC, a notice must be provided at least 60 days before the effective date of the change.
A material change is any change that would be considered by an average participant to be an important enhancement or reduction in benefits. Changes made at annual renewal do not require 60-day advance notice.
Types of plans affected
SBCs are required for: SBCs are not required for:Who is responsible for providing the SBC
SBC timing for employees
SBCs must be provided during each annual enrollment:
The SBC must be provided within 90 days after an individual enrolls due to a special enrollment event. When an employee requests an SBC, it must be provided within seven business days.
Paper and electronic delivery of SBCs to employees
Information may be provided in either paper or electronic format.
If an SBC is provided electronically to currently enrolled employees, the plan must comply with the ERISA rules for electronic delivery.
For employees not yet enrolled, the SBC may be provided electronically by email or posted on the Internet. If posted on the Internet, the location must be prominent and readily accessible and individuals must be notified about where they can access the SBC and that a paper copy is available at no cost on request.
Language requirements
If a certain percentage of the population in a county speaks a language other than English, the availability of materials in the non-English language must be communicated by:
Penalty for noncompliance
The 2020 penalty for willful noncompliance is up to $1,176 per enrollee for each failure to comply. Other ERISA and tax penalties may apply.
Who is responsible for paying penalties?
How SBCs can be delivered to individual policyholders
An SBC may be provided in either paper or electronic format. It may be hand delivered or mailed. It may also be emailed or posted on the Internet after obtaining the individual’s agreement to receive the SBC electronically.
If posted on the Internet, the individual must be notified about where the SBC is posted and that the SBC is available in paper form free of charge upon request.
The electronic version must be in a format that is readily accessible, prominently displayed and in a format that can be electronically saved and printed.
Before receiving an application, an insurer can comply with the requirement to provide an SBC by posting the required information on the health care reform web portal available through www.healthcare.gov.
Individual and family medical and dental insurance plans are insured by Cigna Health and Life Insurance Company (CHLIC), Cigna HealthCare of Arizona, Inc., Cigna HealthCare of Illinois, Inc., Cigna HealthCare of Georgia, Inc., Cigna HealthCare of North Carolina, Inc., Cigna HealthCare of South Carolina, Inc., and Cigna HealthCare of Texas, Inc. Group health insurance and health benefit plans are insured or administered by CHLIC, Connecticut General Life Insurance Company (CGLIC), or their affiliates (see a listing of the legal entities that insure or administer group HMO, dental HMO, and other products or services in your state). Accidental Injury, Critical Illness, and Hospital Care plans or insurance policies are distributed exclusively by or through operating subsidiaries of The Cigna Group Corporation, are administered by Cigna Health and Life Insurance Company, and are insured by either (i) Cigna Health and Life Insurance Company (Bloomfield, CT). The Cigna Healthcare name, logo, and other Cigna Healthcare marks are owned by The Cigna Group Intellectual Property, Inc.
All insurance policies and group benefit plans contain exclusions and limitations. For availability, costs and complete details of coverage, contact a licensed agent or Cigna Healthcare sales representative. This website is not intended for residents of New Mexico.
Selecting these links will take you away from Cigna.com to another website, which may be a non-Cigna Healthcare website. Cigna Healthcare may not control the content or links of non-Cigna Healthcare websites. Details
La aseguradora publica el formulario traducido para fines informativos y la versión en inglés prevalece para fines de solicitud e interpretación.
The insurer is issuing the translated form on an informational basis and the English version is controlling for the purposes of application and interpretation.