Summary of Benefits and Coverage

Posted by BAS - 25 May, 2023


An SBC, or a Summary of Benefits and Coverage, is a standardized document that presents easy-to-understand information about a health insurance plan. The SBC is required under the Affordable Care Act (ACA) and must be provided by health insurance companies and employers offering group health plans.

The purpose of an SBC is to help individuals understand the key features of their health insurance plan, such as deductibles, copayments, and covered services. By providing this information in a standardized format, plan participants can easily compare different health insurance plans and make informed decisions about their healthcare coverage.

What Information is Included in an SBC?

An SBC must include the following information:

  1. A description of the coverage provided by the plan, including deductibles, copayments, and coinsurance.
  2. Examples of the costs under the plan for common medical services, such as office visits and prescription drugs.
  3. A statement explaining any limitations or exclusions on coverage, such as pre-existing condition exclusions.
  4. A description of the process for obtaining prior authorization for certain services, if applicable.
  5. Contact information for the health insurance company or plan administrator.
  6. A glossary of commonly used health insurance terms.

The SBC must also include a standardized set of questions and answers about the plan, such as "What is the overall deductible for the plan?" and "Does the plan cover maternity care?"

How is an SBC Provided?

Health insurance companies and employers offering group health plans must provide an SBC in several different situations, including:

  1. Upon the initial application for health insurance coverage.
  2. When health insurance coverage is renewed.
  3. Upon request.
  4. When there are significant changes to the plan that would affect the information provided in the SBC.

The SBC must be provided in a timely manner, usually within 7 days of a request or renewal of coverage.

In conclusion, an SBC is a standardized document that provides important information about a health insurance plan. By making this information easy to understand and compare across different plans, individuals can make informed decisions about their healthcare coverage.

Topics: Company News, HR & Benefits Compliance, HR & Benefit Plans, HR & Benefits News

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