Group business – SBC distribution requirements
Under its final rule of the Patient Protection and Affordable Care Act, U.S. health insurers and group health plan providers must provide a summary of benefits and coverage (SBC) to participants and beneficiaries who are eligible to enroll or re-enroll in group health coverage through an open enrollment period. The SBC must be distributed on the first day of an open enrollment period that begins on or after September 23, 2012, or on the first day of the plan year on or after September 23, 2012, for special enrollees and those newly eligible for coverage.
NOTE: you can access the forms discussed here in the other resources section below.
New group business, upon selection of the benefit plan:
- Employers must provide the SBCs within seven (7) business days of a request for information related to a specific plan.
Renewals for Group business – basics of SBC distribution requirements:
- The employer has seven (7) business days, starting the day they receive the benefit confirmation to issue an SBC.
- The employer has seven (7) business days from the date the benefit selection is finalized to distribute to eligible employees and dependents.
- If renewal benefits are submitted late, eligible employees and dependents must receive SBC no later than the renewal date.
- When the renewal is automatic and renewal has not been issued at least thirty (30) days prior to the renewal date, then the SBC must be issued within seven(7) business days of the date the benefits were finalized.
Specifics of SBC distribution:
- Must be provided any time requested by the group administrator,
- Open enrollment period – Must be provided with open enrollment materials,
- If the employer does not have an open enrollment period, SBCs must be provided at least thirty (30) days prior to the renewal date,
- When the renewal is automatic and the renewal has not been issued at least thirty (30) days prior to the renewal date, then the SBC must be issued within seven (7) business days of the date the benefits are finalized,
- SBCs must be provided any time it is requested by a member for plan years beginning on or after September 23, 2012, and
- SBC must be distributed to new hire eligible employees after renewal dates, beginning in or after September 23, 2012.
Material modification (does not include switching carriers at renewal):
The proposed regulations clarify that if a group health plan or health insurer makes a mid-year material modification to coverage that affects the content of an SBC, the group health plan or health insurer is your must provide a 60-day advance notice to enrollees. However, the 60-day advance notice rule does not apply to modifications made at renewal/annual open enrollment. A “material modification” is the same as a material modification under ERISA Section 102 (any change to the coverage offered that independently or in conjunction with other contemporaneous changes would be considered by the typical plan participant to be an important change, including changes that enhance or reduce benefits, increase premiums or cost-sharing, or impose new referral requirements).
Uniform glossary of terms:
The proposed rules require that group health plans and health insurance make a Uniform Glossary of Terms available to participants and beneficiaries. The Uniform Glossary may not be modified and must be provided in paper and electronic form on request by a participant or beneficiary within seven (7) days. (A paper version of the uniform glass right must be available on request).
The proposed rules includes a list of health-coverage related terms and medical terms that will need to appear in the Uniform Glossary, which in addition, must include other terms that the Secretary of HHS determines are important to define, so that Individuals and Employers may compare and understand the terms of coverage and medical benefits (including any exceptions to those benefits).
Penalties for noncompliance of SBC distribution:
Employers that sponsor group health plan should start working with your broker to compile the information necessary to meet the SBC requirements.
A group health plan or health insurance insurer that willfully fails to provide an SBC will be subject to a fine of up to $1000 per enrollee who does not receive the SBC.
Additional resources: ACA SBC Regulations and Guidance
Regulations and Guidance
- Final Regulations – June 2015
- Proposed Regulations – December 2014
- Final Regulations – February 2012
- Guidance for Compliance – February 2012
This content is provided for informational purposes only. While we have attempted to provide current, accurate and clearly expressed information, this information is provided “as is” and MNJ Insurance Solutions makes no representations or warranties regarding its accuracy and completeness. The information provided should not be construed as legal or tax advice or as a recommendation of any kind. External users should seek professional advice form their own attorneys and tax and benefit plan advisers with respect to their individual circumstances and needs.