Checklist: What must be included in an SBC?

Uniform definitions
Cross references to Summary Plan Descriptions are not permitted to substitute content requirements

But may include cross references to address items not required to be addressed in the SBC, such as plan eligibility

A description of the plan's coverage for each category of benefits, including exceptions, reductions and limitations
The plan's cost-sharing provisions, such as deductibles, co-pays and coinsurance
Information about renewability and continuation of coverage
Hypothetical coverage examples selected by HHS to illustrate the benefits that would be provided for certain common benefits scenarios (these examples are included in the final regulations)
For coverage beginning on or after Jan. 1, 2014, a statement as to whether the plan provides minimum essential coverage and whether the plan pays at least 60 percent of the total cost of benefit
An internet address (or similar) for obtaining a list of the network providers
An internet address where an individual may find more information about the prescription drug coverage under the group health plan or health insurance coverage
An internet address where an individual may review and obtain the uniform glossary
A disclosure that paper copies of the uniform glossary are available, and a contact phone number for obtaining a paper copy of the uniform glossary
A statement that the SBC is only a summary, and that the plan document, insurance policy, contract or certificate of insurance should be consulted for more information about the coverage provided under the plan
Contact information for questions or for obtaining a copy of the plan document or the insurance policy, contract or certificate of insurance
Premium information
Statement about the grandfathered status of the plan
Barcodes and control numbers
Generic names for benefit package options (i.e., standard option, high option)
Plan's eligibility requirements
Optional: Add-ons to major medical coverage that can affect cost sharing and other information can be combined in the SBC provided the appearance of the SBC remains understandable (examples: FSAs, HSAs)

"I think it's smart for health plans to [also] include some reference to the eligibility requirements in their SBCs, so you're reducing the likelihood of someone claiming that they were told that they have coverage because they received the SBC," McElligott notes. "There's no requirement to have anything about eligibility in there, but I think a reference to the eligibility requirements in the summary plan description is the prudent thing to do."

Instant Insights /

The HR guide to Summary of Benefits and Coverage

More From HR Executive

Related Stories

Recommended For You