SECOND OPINIONS: Summary of Benefits and Coverage Updated Guidance

June 12, 2013 ( - Each year, health plans must provide Summaries of Benefits and Coverage (SBCs) prior to enrollment so that employees can compare plan options in order to make enrollment decisions.

The SBC is based on an eight-page standardized template that requires the plan to complete information about which benefits are covered, levels of coverage, and any restrictions.  Plans also must calculate benefits under two “coverage examples.”

2013 was the first year that SBCs were required.  Many plans were frustrated by the very rigid and detailed instructions for the SBC and found that completing these standardized forms was a lot more complicated than they thought.  The agencies provided some relief for the first year of applicability, including that they would not bring enforcement action if a plan was “working diligently and in good faith” to comply.  ACA FAQs Parts VIII & IX (

Here were are in year two, and the agencies have recently issued updated guidance, including new content for the SBC and extension of some of the year-one relief.


What changes are required for the 2014 SBC?

The guidance updates the SBC content requirements with respect to coverage starting on or after January 1, 2014 (for the 2014 plan year).  The new SBCs must answer two new questions:

·                  Does this coverage provide minimum essential coverage?  

The allowed answer is: "This plan or policy [does/does not] provide minimum essential coverage.”


·                  Does this coverage meet the minimum value standard?  

The allowed answer is: "This health coverage [does/does not] meet the minimum value standard for the benefits it provides."


Presumably, these questions are to help employees understand whether the coverage provided satisfies the ACA's individual mandate or potentially qualifies the employee for a subsidy under the Exchange.  The agencies have posted an updated template that includes these questions.

Are there new coverage examples for 2014?

No - the agencies kept the previous coverage examples – related to diabetes and maternity benefits.  

Did the Uniform Glossary Change?

No - the Uniform Glossary is the same.   Plans must provide the Uniform Glossary upon request within seven days.  It can be found at


Are there updated instructions to complete the SBC for Year Two?

No - the year-one instructions continue to apply.  In addition, the recently released Q&As add the two new questions noted above with some instruction.  Also, the new Q&As clarify how a plan should answer questions related to the plan’s overall annual dollar limit, which no longer is permitted in 2014 under the ACA.  The Q&As provide that a plan either should answer "no" to the SBC question regarding overall annual dollar limits or may remove that row altogether.

Do the previous Q&As providing relief from some of the SBC provisions still apply?

The agencies extended most of the prior Q&As that provided a one-year transition period, including the Q&A adding a temporary “good faith” non-enforcement policy, the Q&A related to how SBCs may be delivered via online enrollment, and the exceptions for expatriate coverage and Medicare Advantage benefits.  The complete list of Q&As that were extended can be found in the new Q&A guidance.

When must SBCs be provided?

As with year one, SBCs must be provided at enrollment (including to HIPAA special enrollees), by the first day of coverage if information has changed, upon renewal, and within seven business days upon request.  For current enrollees, plans only are required to provide the SBC at renewal for the option in which the individual is enrolled (although they can request other SBCs). 

The Q&A guidance can be found at  Alternatively, go to and click on the Affordable Care Act tab and go to "FAQs about the Affordable Care Act Implementation Part XIV."