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 your 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 this document 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. SBCs will be created 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 you offer more than one plan to your employees, only the SBC specific to the plan for which an employee is eligible must be provided to that employee at renewal. However, if an employee asks to see a different plan’s SBC, you must also provide it 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 (please refer to How often will employees need to receive an SBC? below), except during initial enrollment and open enrollment periods, when we will rely on the group official to provide it to employees.

    Self-funded groups: We will provide the SBC to the group official, who is responsible for distributing it to employees at the required times (please refer to How often will employees need to receive an SBC? below).

    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 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 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 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
    • Upon request

    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?

    Enrolled members:

    • Call Customer Care at the toll-free number on their identification (ID) card to request either a paper or electronic copy
    • Log in to My Health Plan on MedMutual.com to view and/or print the SBC

    Group officials:

    • 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

    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? Can I stop giving the SBC to my employees/participants?

    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 their 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 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.

    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 produce its own SBC?

    Yes. If a self-funded group wants to produce its own SBC, we will not produce and deliver SBCs to the group official or its employees.

    Can a self-funded group ask Medical Mutual to provide SBCs to its employees?

    No, we will not provide SBCs to employees of self-funded groups at this time.

    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.

    Certificate Books

    Certificate books describe what is covered by your plan. Sample certificate books for Medical Mutual products can be viewed below. Additional plans are available.