Compliance Briefing Center

Regulatory Updates

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Final Instructions for Completing Summary of Benefits and Coverage (SBC) Templates

 

Background
On June 16, 2015, final regulations concerning the requirements of Summary of Benefits and Coverage (SBC) were published for all group health plans, including Health Reimbursement Accounts (HRAs). See our previous Compliance Alert for additional background on the regulations. However, the necessary changes to the SBC template were not released until April, 2016. Text for the template and supplementary materials are to be utilized beginning on the first day of the first open enrollment period that begins on or after April 1, 2017. That means plans with a plan year beginning date of January 1 would begin to employ the new template for open enrollment starting in late 2017 for the January 1, 2018 plan year.

For all SBCs 

Changes made to the SBC improve readability for consumers, provide more information about cost sharing, enhance language to explain deductibles, and address individual and overall out-of-pocket limits.

Form language and formatting must be precisely reproduced, unless instructions allow or instructed otherwise. Use 12 point font preferably in Arial and Garamond and replicate all symbols, formatting, bolding and shading where applicable. Changes from the sample are generally not permitted.

Detailed instructions for group health plan coverage and individual health insurance coverage are available from the Centers for Medicare and Medicaid Services (CMS). 

The SBC template, completed sample SBC, and all SBC materials and supporting documents authorized for use on and after April 1, 2017, are available at the CMS website.

This helpful link provides all the regulations and guidance plus SBC template, instructions, and related materials for use on or after April 1, 2017.

Integrated HRAs 

HRAs are considered group health plans and HRA information must be included on all SBCs for health plans integrated with HRAs. WageWorks has prepared sample language for an integrated HRA that may be added to the SBC for your major medical plan: 

  1. In the Answers column to the first row- “What is the overall deductible?” on page 1 add the following language: 
    “If you participate in your employer’s HRA, the HRA will pay for or reimburse you for certain, qualified medical expenses (including co-pays and coinsurance) up to the balance available in your HRA.” Your HRA has an overall limit of $XXXX per plan year, even if your need is greater. You’re responsible for all expenses above this limit. The chart starting on page 2 describes specific coverage limits, such as limits on the number of office visits.
  2. A text box should be added following the Coverage Examples on page 5 of 5 in the example that states:
    “If you participate in your employer’s HRA, the HRA will pay for or reimburse you for certain, qualified medical expenses (including co-pays and coinsurance) for amount under the deductible, up to the balance available in your HRA.” Your HRA has an overall limit of $XXXX per plan year, even if your need is greater. You’re responsible for all expenses above this limit.

Stand-Alone HRAs

HRAs not integrated with group health plan coverage will use the template used for all group health plans.

Contact your current health care provider for additional information on SBCs.

Download a copy of this Alert.