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Agencies Issue Final Regulations on the Summary of Benefits and Coverage (SBC) Requirements

As promised in the FAQ issued on March 30, 2015, the U.S. Departments of the Treasury, Labor and Health and Human Services  (the Departments) have issued final regulations regarding the summary of benefits and coverage (SBC) and uniform glossary for group health plans and health insurance coverage in group and individual markets under the Patient Protection and Affordable Care Act (ACA).  These regulations finalize, with very few changes, the proposed regulations issued on December 30, 2014.  The final regulations state that the Departments anticipate a new SBC template and associated documents will be issued by January 2016 and will apply to coverage that begins or is renewed after January 1, 2017.

These final regulations make changes to the initial SBC regulations, issued on February 14, 2012, and codify certain guidance previously set forth in the FAQs about Affordable Care Act Implementation

The changes and clarifications are summarized as follows:

  • If an SBC was provided to an individual or entity prior to the individual or entity submitting an application for coverage, then unless any of the information has changed in the interim, there is no obligation to provide the SBC upon application. The regulations set forth the timing requirements for providing a new SBC if the information has changed.

  • If an entity contracts with a third party to provide SBCs, the contracting entity must monitor the third party. As soon as the contracting entity becomes aware of any non-compliance, it must take certain steps to correct the non-compliance and avoid future violations.

  • If a plan uses a combination of products from separate issuers (or self-insures certain benefits), individual issuers might not have all of the information required to provide a complete SBC. Accordingly, in such circumstances the group health plan administrator is the only entity responsible for providing complete SBCs to participants and beneficiaries, and in certain cases multiple SBCs may be provided with respect to one plan.

  • If an individual with individual market coverage is automatically re-enrolled in a different plan or product than he or she was previously enrolled in, the issuer must provide an SBC with respect to the new coverage, consistent with the timing requirements that apply when a policy is renewed or reissued.

  • Until the new template SBC is released, plans and issuers can continue to use the Minimum Essential Coverage and Minimum Value language set forth in the 2013 template, which may be provided in a cover letter if the SBC cannot be modified to include such language.

  • Qualified Health Plans sold through individual market Exchanges must disclose on the SBC (or, until the new template is issued, in a cover letter) whether abortion services are covered or excluded, and whether coverage is limited to services for which federal funding is allowed.

  • All plans and issuers must include in the SBC contact information for the consumer to call with questions.

  • Individual coverage policies and group certificates of coverage must be posted to an Internet address easily available to individuals, plan sponsors, participants and beneficiaries prior to their submitting an application. For the group market, if the terms have not yet been finalized by the plan sponsor and issuer, then posting samples for each applicable product is sufficient, with the actual certificate of coverage to be made available after it is executed.

  • SBCs may be provided electronically to participants and beneficiaries in connection with their online enrollment or online renewal of coverage, and to participants and beneficiaries who request an SBC online. Paper copies must be made available upon request.

  • SBCs provided by a self-insured non-Federal government plan may be provided in paper form, or may be provided electronically if the plan conforms to the electronic disclosure requirements for either ERISA plans or individual health insurance coverage.

  • Willful failure to provide the required information is subject to a fine. The DOL and IRS set forth the processes and procedures to be used for enforcement.

  • Group health plan benefit packages providing Medicare Advantage benefits are exempt from the SBC requirements.

  • The SBC requirements will not be enforced with respect to insurance products that are no longer offered for purchase if they have not been actively marketed since before September 23, 2012, and if the health insurance issuer has never provided an SBC with respect to the product.

The final regulations are effective as follows:

  • For disclosures to participants and beneficiaries enrolling or re-enrolling in group coverage, on the first day of the first open enrollment period beginning on or after September 1, 2015 (or the first day of the first plan year beginning on or after September 1, 2015 for those not enrolling through an open enrollment period).

  • For disclosures to plans, on September 1, 2015.

  • For disclosures to individuals and dependents in the individual market, on January 1, 2016.

© 2020 Proskauer Rose LLP.


About this Author

Katrina E McCann, Proskauer Rose, Tax Lawyer, ERISA Attorney, Benefits

Katrina McCann is an associate in the Tax Department and a member of the Employee Benefits, Executive Compensation & ERISA Litigation Practice Center.

Katrina previously served as Special Assistant to the Mayor’s Office of Pension and Investments, assisting New York City’s Chief Pension Administrator with projects to improve the benefits administration, board processes, investment decision-making, and governance of City plans with a combined $130 billion under management. Before that she was Special Assistant Corporation Counsel, Pensions...

Ahuva Warburg, Tax lawyer at Proskauer Rose Law firm

Ahuva Warburg is an associate in the Tax Department and a member of the Employee Benefits, Executive Compensation & ERISA Litigation Practice Center.

Ahuva represents multiemployer and single employer benefit plan clients, including public and private companies and non-profit institutions, with respect to a variety of tax and benefits issues, including plan administration, design, compliance and qualification issues. She advises welfare and retirement plan clients on matters affecting ongoing legal compliance with the Internal Revenue Code, ERISA, COBRA and HIPAA, as well as the numerous other federal and state laws affecting employee benefit programs. In addition to providing advice with respect to day-to-day employee benefits issues, Ahuva represents clients in the preparation of formal plan documents and participant communications.