On April 6, 2016, the Department of Health and Human Services, Department of Labor and Department of the Treasury (collectively, the Departments) issued changes to the Summary of Benefits and Coverage (SBC) template and glossary.

What are some of the major changes?

  • New Coverage Example – The current form includes examples to show cost-sharing that would apply for diabetes care and childbirth. The new form also includes an emergency situation caused by a foot fracture.
  • Out-of-Pocket Limits – The new form requires that plans describe the individual and overall out-of-pocket limits that apply. The new form includes standard language to use for “embedded” and “non-embedded” out-of-pocket limits.
  • Preventive Services – A description of preventive services that are covered without cost-sharing must be included in the SBC.
  • Abortion Services – If covered under the plan, abortions should be listed in the “other covered services” section. If excluded or only available in limited cases, abortions should be listed in the excluded section with the exceptions listed in a parenthetical.
  • Optional Changes – One SBC covering all deductible, coinsurance and copay levels may be used, as opposed to offering a separate SBC for each option. In addition, information regarding HRAs, HSAs, FSAs and wellness programs may be included in the SBC.

When is compliance required?

The updated SBC must be used for the first open enrollment period that begins on or after April 1, 2017. For a group health plan with a plan year that coincides with the calendar year, the updated SBC should be used in the open enrollment period that applies to the 2018 plan year. If the plan year is a fiscal year, you may be required to use the updated SBC earlier. For example, for a plan year ending June 30th, the updated SBC should be used in the open enrollment period that applies for the plan year beginning July 1, 2017, if the open enrollment period for that plan year begins on or after April 1, 2017.