Guidance for self-funded employers regarding the Summary of Benefits and Coverage provision in PPACA

1. Summary of Benefits and Coverage
Guidance
A Provision of the Patient Protection
and Affordable Care Act

2. Summary of Benefits and Coverage
Uniformity
Beginning September 23, 2012,
employers that sponsor a self-funded
group health insurance program will
be required to provide a standard
Summary of Benefits and Coverage
to all individuals enrolling in the
medical coverage.

3. Requirements of the Self-funded
Employer
• The SBCs must be provided to employees when
shopping for coverage
• The SBCs must be provided to employees when
enrolling in coverage
• The SBCs must be provided to employees at each
new plan year
• The SBCs must be provided to employees within 7
days of the employees’ request of the document
• The SBCs must be distributed with Open Enrollment
materials that begin on, or after, September 23,
2012
• The SBCs must be provided to employees at least
30 days before the beginning of the new plan year if
the coverage continues automatically
• The SBCs must be provided to employees if the
coverage changes during the plan year

4. Information That Must Be Included in
the Summary of Benefits and Coverage
• A four-page Benefit Summary (two-sided, 8 pages
maximum, 12-point font, in color or grayscale) presented
as a freestanding document or incorporated into other
plan documents, placed at the front
• Information about covered benefits, cost sharing and
exclusions-other similar documents will not satisfy the
requirement of the regulations
• The specific form and instructions for completion
provided in the regulations
• Coverage examples showing estimated customer costs
based on each plan’s benefits for two medical scenarios –
Having a baby and Managing Type 2 Diabetes are a couple
of examples
• A prominently displayed website and phone number where
individuals can get additional information
• A standard Glossary document including definitions and
common insurance terms
• The Glossary must be provided upon request of the
employee

5. Distribution of the Summary of
Benefits and Coverage to the
Employees
• The Summary of Benefits and Coverage must be
provided when an employee requests information
about the plan, applies for coverage or enrolls in the
plan
• If any benefit changes are made before the
coverage becomes effective
• The SBCs must be provided within 60 days after an
individual enrolls due to a special enrollment event
• The SBCs must be distributed to employees during
the annual enrollment period for the plan in which
the employee is enrolled
• The SBCs must be provided within 7 days of the
request of the employee
• If any material change is made to a plan during the
plan year that is not reflected in the most recent
SBC, a notice must be provided within 60 days
before the effective date of the change

6. Various Formats of the Summary of
Benefits and Coverage
• Summary of Benefits and Coverage may be provided
in Paper and/or Electronic form
• If the SBCs are provided electronically to currently
enrolled employees, the plan must comply with the
ERISA rules for electronic delivery
• If posted on the Internet, or Intranet, the SBCs must
be displayed in a location that is prominent and
readily accessible while notifying each employee
where they can access the information and that a
paper copy is available upon request
• The employer must promptly provide a paper copy
upon request of the employee
• The SBCs must be available in the non-English
language while offering language assistance and
providing translation upon request