Smart Benefits: Revised SBC Template Proposed

Rob Calise, GoLocalProv Business/Health Expert

Smart Benefits: Revised SBC Template Proposed

Under the Affordable Care Act, group health plans and health insurance issuers are generally required to provide a written Summary of Benefits and Coverage (SBC) to plan participants during the enrollment process and upon request. The SBC is designed to allow individuals to make apples-to-apples comparisons among available health plans and help enrollees better understand and use their own coverage. 

The Departments of Health and Human Services, Labor, and Treasury recently proposed a revised SBC template, individual and group instructions, and uniform glossary. Use of the new SBC template and related materials is required starting with the first day of the first plan year that begins on or after April 1, 2017.

Some of the changes reflected in the new proposed SBC template and accompanying instructions include: 

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•    A new question identifying any services covered before the deductible is met
•    A new instruction requiring the use of specific language to identify whether the plan has “embedded” or “non-embedded” deductibles or out-of-pocket maximums
•    A new instruction requiring the use of specific language to identify whether the plan uses a tiered network to alert participants that costs for in-network services may vary depending on the tier of the physician or facility
•    A new instruction requiring a list of certain “core” limitations, including when cost-sharing for in-network services does not count towards the out-of-pocket limit (for example, cost-sharing for in-network items or services that are not essential health benefits), prior authorization requirements, visit limits, or exclusion of a particular service category or substantial part of a service category (for example, exclusion of brand name drugs if the plan only covers generic drugs)
•    A new coverage example for a simple fracture

The new proposed template also includes a statement indicating whether the plan meets Minimum Essential Coverage (MEC) and Minimum Value (MV).  

Rob Calise is the Managing Director, Employee Benefits. of Cornerstone|Gencorp, where he helps clients control the costs of employee benefits by focusing on consumer driven strategies and on how to best utilize the tax savings tools the government provides. Rob serves as Chairman of the Board of United Benefit Advisors, and is a board member of the Blue Cross & Blue Shield of RI Broker Advisory Board, United HealthCare of New England Broker Advisory Board and Rhode Island Business Healthcare Advisors Council. He is also a member of the National Association of Health Underwriters (NAHU), American Health Insurance Association (AHIA) and the Employers Council on Flexible Compensation (ECFC), as well as various human resource associations. Rob is a graduate of Bryant University with a BS in Finance

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