What does SBC mean?
SBC is short for Summary of Benefits and Coverage. It is a document intended to help people understand their health coverage and compare health plans when shopping for coverage.
What is the Uniform Glossary?
The Uniform Glossary is a list of commonly used healthcare terms and their definitions that was designed for use with the SBC. Terms and definitions may differ from those used in other plan documents describing a plan’s coverage.
What is the purpose of the SBC and Uniform Glossary?
The SBC and Uniform Glossary are meant to help people understand their healthcare coverage and the common terms used by health plans. SBCs must be provided by all insurance companies and group health plans in a standard format and may only be different based on the specific benefits offered by a plan. This standard format will help simplify comparing and shopping for health plans.
Why is the SBC being issued?
The federal government requires all healthcare insurers and group health plan sponsors to provide this document to plan participants at certain times beginning September 23, 2012 (please refer to questions below). We created an SBC for each medical plan offered through Medical Mutual and its Family of Companies.
Group health plan sponsors must provide a copy of the SBC to each employee eligible for coverage under the plan. If more than one plan is offered to the group’s employees, only the SBC specific to the plan for which an employee is eligible must be provided to that employee. However, if an employee asks to see a different plan’s SBC, that SBC must also be provided so he or she can compare plans.
Fully insured groups: We will provide the SBC to both the group official and the employees at the required times, except during initial enrollment and open enrollment periods, when we will rely on the group official to provide it to employees (please refer to question 13 below for where to get a copy of the group’s SBC).
Self-funded groups: We will provide the SBC to the group official, who is responsible for distributing it to employees at the required times.
What information is included in the SBC?
The SBC includes:
A summary of the services covered by the plan
A summary of the services not covered by the plan
The copays and/or deductibles required by the plan, but not the premium
Information about members’ rights to continue coverage
Information about members’ appeal rights
Examples of how the plan will pay for certain services
What do the coverage examples in the SBC show?
The federal government requires all insurance companies and group health plans to provide two examples of covered services under the plan. The two examples are having a baby and managing type 2 diabetes.
The examples are not intended to show exact costs, because each person’s care will be different. Instead, the sample costs are based on national averages supplied by the Department of Health and Human Services. They are not specific to a certain geographic area or health plan.
These examples should help compare coverage between plans. The “Patient Pays” box at the bottom of each example shows how each plan offers more or less coverage for these two conditions.
Will HRA or FSA information be included on SBCs?
No. Money from a health reimbursement account (HRA) or flexible spending account (FSA) that is used to pay for out-of-pocket expenses would not be included in the coverage examples shown on an SBC. Members will see the following disclaimer:
“These numbers assume that the patient does not use an HRA or FSA. If you participate in an HRA or FSA and use it to pay for out-of-pocket expenses, then your costs may be lower. For more information about your HRA or FSA, please contact your employer group.”
How often will a group health plan’s employees need to receive an SBC?
Beginning September 23, 2012, insurers and group health plan sponsors are required to provide the SBC to eligible employees and plan participants at these various times:
When an employee is first eligible for coverage
At renewal/open enrollment
By the first day coverage starts, if the SBC changed from the version provided during annual open enrollment
After a request for special enrollment, as defined by HIPAA
If there is a mid-year change to the plan that affects the information in the SBC
How often will individual clients need to receive an SBC?
Beginning September 23, 2012, insurers are required to provide the SBC to individuals at various times, whether they have coverage through the insurer or if they are shopping to buy coverage:
When an individual applies for coverage
By the first day the individual’s coverage starts, if the SBC changed from the version provided when he or she enrolled
If there is a change to the individual’s plan that affects the information in the SBC
When the individual’s coverage is renewed
Where can a client who is shopping for insurance find SBCs for your plans?
Individuals shopping for health insurance should visit the Department of Health and Human Services’ website at Healthcare.gov to view our individual health plan information.
Brokers can also log in to MyBrokerLink to find SBCs for our individual health plans and small group products.
If a plan is grandfathered, is the SBC still required?
Yes. All insurers and group health plan sponsors, whether a plan is grandfathered or non-grandfathered, are required to provide the SBC to all eligible employees and plan participants.
Are any plans exempt from the requirement to provide an SBC?
An SBC is required for most health plan types. SBCs are not required if a plan, policy or benefit package is considered a “HIPAA-excepted benefit.” Some examples of HIPAA-excepted benefits are dental-only plans, vision-only plans and some flexible spending accounts (FSAs).
Health Reimbursement Accounts, or HRAs, are group health plans and are not typically considered HIPAA-excepted benefits. Plan sponsors and issuers must provide SBCs for HRA plans.
Health Savings Accounts, or HSAs, are not typically considered group health plans and therefore do not require an SBC. However, if the HSA is tied to a high-deductible health plan (HDHP), the HDHP is considered a group health plan and plan sponsors and issuers must provide an SBC for the HDHP.
Once the SBC and Uniform Glossary are available, how can a copy be requested?
Contact their Medical Mutual or Carolina Care Plan representative, Business Distribution Solutions representative, or broker to request either a paper or electronic copy
Log in to EmployerLink to view and/or print the SBC(s) specific to their group
Contact your Medical Mutual, Carolina Care Plan or Business Distribution Solutions representative to request a paper or electronic copy of a group’s specific SBC
Log in to MyBrokerLink for your enrolled groups’ SBCs and standard product offerings for our small group (2–50) and individual products
Will there be a charge for providing the SBC?
We will not charge a member for the SBC. We will deliver one copy of each plan’s SBC to a group official at no charge. Additional fees may apply if a group asks us to provide SBCs beyond what is required by the Affordable Care Act (ACA).
Can a member stop receiving the SBC?
No. Providing the SBC is required by the ACA.
What will happen if the SBC is not provided to employees/participants?
Group health plan sponsors and health insurance issuers that do not provide the SBC to its employees, participants or members may be subject to fines.
Will Medical Mutual and it Family of Companies be compliant with the SBC requirements defined by the Affordable Care Act?
Yes, Medical Mutual and is Family of Companies will be compliant with the SBC requirements defined by the ACA.
What is the earliest date Medical Mutual will provide a copy of a plan’s SBC?
In accordance with the ACA, we will have SBCs for current benefits available beginning September 23, 2012. The first time a group official will need to distribute an SBC to its participants depends on the date of its first open enrollment period and its first plan year, as described below:
For participants enrolling in plans during open enrollment periods, the group official must distribute the SBC to its participants during the first open enrollment period held on or after September 23, 2012.
For participants enrolling at other times (including newly eligible and special enrollees), the group official will need to provide the SBC to its participants beginning with its first plan year on or after September 23, 2012.
For individual plans, SBCs for current benefits will be available beginning September 23, 2012.
Will Medical Mutual provide a draft of my plan’s SBC?
No. We will not provide draft copies of a plan’s SBC.
Can a self-funded group create its own SBC?
Yes. If a self-funded group wants to create its own SBC, we will not produce and deliver SBCs to the group official or its employees.
If a group offers several different health plans from Medical Mutual and other insurance companies, can all the plans be combined on one SBC?
No. We will provide SBCs only for coverage we administer or insure.
Will Medical Mutual customize my group’s SBC, for example, with my company’s logo?
No. SBCs cannot be customized in any way other than the plan’s specific benefits.