In 2019 the Centers for Medicare and Medicaid Services (CMS) revised the Summary of Benefits and Coverage (SBC) materials and supporting documents for use for plan and policy years that begin on or after January 1, 2021. The revisions to the forms and templates reflect the elimination of the individual mandate requirement, which became effective for the 2019 plan year. The new SBC forms and materials can be found at this link.

Action Needed: All SBC materials for plan and policy years beginning on and after January 1, 2021 must comply with the new requirements.

Background

The Affordable Care Act (ACA) requires group health plans and health insurance issuers offering group or individual health insurance coverage to issue an SBC that "accurately describes plan benefits or coverage." In addition, they must make a uniform glossary available to participants and beneficiaries.

Overview of Significant Changes

• Certain Changes to the SBC:
  • Minimum Value. A “Not Applicable” answer option (in addition to the current “Yes” and "No” options) has been added to the question “Does this plan meet the Minimum Value Standards?” “Not Applicable” should only be used for individual coverage.
  • Minimum Essential Coverage. The text under the heading, “Does this plan provide Minimum Essential Coverage?” now includes a description of minimum essential coverage.¹ In addition, reference to the requirement to have health coverage (the individual mandate) has been eliminated from this section. The section now contains the statement: “If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.”
  • Coverage Examples. A number of changes were made to the Coverage Examples provided at the end of the SBC.  Likewise, the Calculator that HHS had provided to help plan sponsors provide the correct numbers for the three required examples has been updated. A Crosswalk of Changes document provides a detailed list of all of the updates made to the Summary of Benefits and Coverage Calculator and three example medical scenarios.
• Changes to the Uniform Glossary:

• •  References to the individual mandate were eliminated.

New SBC Materials and Supporting Documents (Required for use for plan or policy years that begin on or after January 1, 2021)

Plans and issuers will be required to use the 2021 Summary of Benefits and Coverage (SBC) on the first day of the first open enrollment period relating to coverage for any plan years (or, in the individual market, policy years) that begin on or after January 1, 2021. Generally, the following materials also are available in Chinese, Spanish, Navajo, and Tagalog formats.

Below are links to forms and tools for completing the SBC.

• Forms:
  • Summary of Benefits and Coverage (SBC) Template
    • Standard Format (DOC)
    • Accessible Format (PDF)

• • Uniform Glossary

• • • English (PDF)
    • List of anchors for SBC Uniform Glossary terms on https://www.HealthCare.gov/sbc-glossary/
• Instructions/Guidance:
  • Sample Completed SBC
    • Standard Format (DOC)
    • Accessible Format (PDF)

• • Instructions for Completing the SBC – Group Health Plan Coverage (PDF) (for January 1, 2021)

• • Guide for Coverage Examples Calculations – Maternity Scenario

• • • Standard Format (XLSX)
    • Accessible Format (PDF)

• • Guide for Coverage Examples Calculations – Diabetes Scenario

• • • Standard Format (XLSX)
    • Accessible Format (PDF)

• • Guide for Coverage Examples Calculations – Simple Foot Fracture Scenario

• • • Standard Format (XLSX)
    • Accessible Format (PDF)

• • Coverage Examples Calculator Instructions(PDF)
  • Coverage Examples Calculator(XLSM) (for use on or after January 1, 2021)
  • Crosswalk of Changes(PDF) (describes updates made to the Coverage Examples Calculator)

CHEIRON OBSERVATION: Overall, there are fewer 2021 revisions, than there were with the 2016 revisions.

Cheiron is an actuarial consulting firm that provides actuarial and consulting advice. However, we are neither attorneys nor accountants. Accordingly, we do not provide legal services or tax advice.

¹The revised SBC states “Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid, CHIP, TRICARE, and certain other coverage.”