Summary of Benefits and Coverage - FAQs
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 may differ from those used in other plan documents describing a plan's 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 the SBC 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 (please refer to questions below). We created an SBC for each plan offered through Easy Choice Health Plan of New York.
For non-enrollees, group health plan sponsors must provide a copy of the SBC to each employee eligible for coverage under the plan. If more than one plan is offered to the group's employees, only the SBCs specific to the plans for which an employee is eligible must be provided to that employee. However, if an employee asks to see a different plan's SBC, that SBC must also be provided so he or she can compare plans. For current enrollees, group health plan sponsors must provide a copy of the SBC for which the employee is currently enrolled. However, if an employee asks to see a different plan's SBC, that SBC must also be provided so he or she can compare plans.
We will provide the SBC to your Benefits Administrator to provide to their employees during initial enrollment, open enrollment, when special enrollees join the plan (e.g. as a result of marriage or birth) and when material changes are made to the SBCs. Please refer to question 13 below for where to get a copy of your group's SBC.
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 co-pays 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 individuals 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 these 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 annual 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
How can I obtain an SBC for Easy Choice Health Plan of New York?
Individuals and groups shopping for health insurance should contact Easy Choice Health Plan of New York at (866) 747-8422, option 3 and then option 1 or send an email to firstname.lastname@example.org.
Brokers and groups already receiving health insurance coverage from Easy Choice Health Plan of New York should contact Easy Choice Health Plan of New York at (866) 747-8422, option 3 and then option 2 or send an email to email@example.com. SBCs may also be obtained via the Easy Choice website (www.easychoiceny.com)
Current members should call (866) 747-8422, option 1 or send an email to EasyChoiceSBC@easychoiceny.com.
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).
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 Benefits Administratorat 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?
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 its employees, participants or members may be subject to fines of up to $1,000 per enrollee.
Will Easy Choice Health Plan of New York be compliant with the SBC requirements defined by the Affordable Care Act (ACA)?
Yes, Easy Choice Health Plan of New York will be compliant with the SBC requirements defined by the ACA.
What is the earliest date Easy Choice Health Plan of New York will provide a copy of a plan's SBC?
In accordance with the ACA, SBCs for current benefits are available beginning September 23, 2012. The first time a Benefits Administrator will need to distribute an SBC to its participants depends on 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 Benefits Administrator 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 Benefits Administrator will need to provide the SBC to its participants beginning with its first plan year on or after September 23, 2012.
For individual plans, SBCs for current benefits will be available beginning September 23, 2012.
If a group offers several different health plans from Easy Choice Health Plan of New York and other insurance companies, will Easy Choice combine all the plans into one SBC?
No. Easy Choice will only provide SBCs for coverage we insure.
Will Easy Choice Health Plan of New York customize my group's SBC, for example, with my company's logo?
No. SBCs will not be customized in any way other than the plan's specific benefits covered by Easy Choice Health Plan of New York.Last updated November 2012
Easy Choice Customer Services is available at 1-866-747-8422, Monday - Friday, 9AM - 5PM.
Easy Choice Health Plan of New York is a marketing name for Atlantis Health Plan, Inc.