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Summary of benefits and coverage FAQs

Frequent questions and answers for employers

Frequent questions and answers for employers

The Affordable Care Act (ACA) requires that group and individual health plans provide a Summary of Benefits and Coverage (SBC) that follows a standard format.

If you sponsor one of our group health plans, we’ll give you the information you need. Then it’s your role to provide the SBC to employees. The requirements apply to both self-funded and insured plans.

The Department of Health and Human Services (HHS) published regulations in 2012 and 2015 to guide employers in creating accurate SBC documents. These standards cover what must be included and how to present the information. You can find the complete rules in the Federal Register.
 

 Look up the rules for creating SBC documents
 

We want to help you understand how to meet your obligation to provide accurate SBC documents to employees. Here are some general answers to commonly asked question

The standards are designed to guide the construction of the SBC in appearance, language, form and contents.
 

Appearance
An SBC must be presented in a “uniform format.” It may not exceed four pages in length. The print must be at least 12-point font.  The final rule allows four double-sided pages.
 

Language
An SBC must be presented in a way that is culturally appropriate for the intended audience. It must use language that the average plan enrollee can understand. The final rule requires that people be told they can get copies of the SBC in non-English languages. You must  support requests for assistance in specific languages that are based on county-level census data.
 

Form
An SBC can always be provided in paper form. It can be provided in electronic form if additional requirements are met.  The final rule has varied requirements for electronic delivery depending on the market involved and  whether or not the participant is enrolled in coverage now.
 

Content
 

At a minimum, ACA requires an SBC to include:
 

  • Uniform definitions of standard insurance and medical terms
  • A description of the coverage, including: Cost sharing, exceptions, reductions and limitations on coverage, cost-sharing provisions, such as deductibles, copays and coinsurance, how to renew or continue coverage and coverage examples
  • A statement of whether the plan or coverage provides minimum essential coverage and minimum value, as defined by the ACA
  • A statement that the outline is a summary and that the coverage document itself contains the controlling contract provisions
  •  A contact number that people can use to ask questions or obtain a copy of the plan document or policy

The final rule also specifies who should provide the SBC and when, and who should receive it.

  • When people apply
  • After they enroll
  • When they renew a plan
  • When there’s a change during the plan year
  • When they ask for a copy

Yes, under the final rule a plan or issuer would be required to make the uniform glossary available upon request.  The uniform glossary is a standard document that must be provided in the form that was issued by HHS.

Yes. Section 2715 of the Public Health Services Act (PHSA) allows for a $1,000 fine to be imposed for each willful failure to comply with the section. Such a fine can be imposed for each person enrolled in the plan. These penalties are in addition to other ACA penalties related to insurance market reform rules.

If a health plan or issuer makes any material change to the terms of the plan or coverage that is not reflected in the most recent SBC, it must notify enrollees of the change. This is called a Notice of Material Modification. Such notice must be given at least 60 days in advance. This can be a separate notice or an updated SBC. Renewing the plan does not trigger the requirement for notice if the plan has not changed.

Expatriate plans are not specifically exempted from the SBC requirements. However, there is a special rule for coverage provided outside of the United States. The rule allows a plan or issuer to provide an Internet address (or similar contact information) for obtaining information about coverage or benefits instead of an SBC. SBCs are only required for plans categorized as “U.S. Locals” plans. 

Yes. The Guidance for Compliance and the SBC instructions provide for a special rule.  This rule applies when a plan’s terms that must be included in the SBC cannot be reasonably described consistent with the template and the instructions. In this case, the plan or issuer must accurately describe the plan’s terms while using its best efforts to remain consistent with the instructions and template.

Plan Sponsor Message:
Each day the post office returns member print material for undeliverable addresses or for a change of address.  Help us make sure we get health plan information to your employees timely and accurately:

  • During open enrollment, encourage your employees to review their address and make appropriate changes
  • Throughout the year, ensure all employee address changes are sent to Aetna via your monthly enrollment process

Member Message:
Help us get your health plan information to you timely by making sure we have your correct mailing address.  If you need to change your address with us, contact your employer, payroll office or your plan’s retirement office to update your permanent address. They will provide it to us.

Legal notices

Aetna is the brand name used for products and services provided by one or more of the Aetna group of companies, including Aetna Life Insurance Company and its affiliates (Aetna).

Health benefits and health insurance plans contain exclusions and limitations.

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