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New Summary of Benefits and Coverage Template Must Be Used Now


There is a new Summary of Benefits and Coverage template that health plans will be required to use during open enrollment for the 2018 plan year.

The new templates were introduced in 2016 and took effect for plan year or open enrollment periods beginning on or after April 1, 2017.

The new template is the first major revision of the SBC template since 2012, the first year that health plans were required to use them as required by the Affordable Care Act.

The new template has a number of changes that you should know about:

  • There is a new row on the first page where the plan must indicate if there are any services that are covered before the individual satisfies the plan’s deductible. It lists a number of categories for these services.
  • There is more detailed information about exclusions and limitations for services related to common medical events like:
    • Whether an entire category of services is excluded from coverage;
    • When in-network cost sharing does not count toward the out-of-pocket maximum;
    • Any limits on the number of visits (or if a specific dollar limit – where permissible – applies); and
    • When prior authorization is required.
  • There is now a third example that is required on the summary to illustrate how costs are paid for. The new example illustrates treatment of a simple fracture with an in-network emergency room visit and follow-up care.
  • The instructions have also changed the way cost sharing is calculated for coverage examples to account for if the individual is enrolled in a wellness program that may affect cost sharing. For example, some wellness plans include incentives or disincentives that reduce or increase plan deductible, coinsurance or copayments.

The new SBC template has also jettisoned some information, such as:

  • A header appearing on the top of every page. Now the header is only required for the first page.
  • A question and answer section about the coverage examples.
  • References to annual dollar limits on essential health benefits are no longer included, as plans may no longer impose them.
  • Certain definitions have been removed.

What you need to do

Insurance carriers will create the new SBCs for you to distribute to your employees. But you will want to confirm that your insurance company is using the new form.

Also, if you are using more than one insurance company for your employee benefits, you may need to work with your health plans to create a single SBC that complies with the new template.

As open enrollment season is quickly approaching, you can plan for your communications by incorporating the new SBC.