Guidelines for the Summary of Benefits and Coverage (SBC) Document as it applies to EAPs
Introduction: What is an SBC and how does it apply to EAPs?
Under the Patient Protection and Affordable Care Act, as of September 23, 2012 or soon after, health insurance issuers and group health plans are required to provide patients with an easy-to-understand summary about a health plan’s benefits and coverage. The new regulation is designed to help them better understand and evaluate their health insurance choices.
All insurance companies and group health plans must use the same standard SBC form to help patients compare health plans. The SBC form also includes details, called "coverage examples," which are comparison tools that allow them to see what the plan would generally cover in two common medical situations. A uniform glossary of terms commonly used in health insurance coverage, such as "deductible" and "copayment" is also required.
At this time, it appears that most EAPs providing services in the U.S. fall under the SBC requirements. This is because the U.S. Department of Labor has defined programs that provide “assistance in dealing with a wide range of major personal problems affecting mental or physical health” through the use of "trained counselors" as group health plans.
Therefore, as a service to its members, EAPA has developed a number of resources to assist EAPs (both internal and external) in complying with the SBC requirements. These resources include a sample SBC form for EAPs with clarifying instructions for completion, a blank SBC template that EAPs can use to insert their own specific language, and a frequently asked question (FAQ) section.
Regulators have indicated that they will accept good faith compliance during the first year the SBC requirement is in place, and that the compliance obligations are likely to change over time, especially after the first year. Nevertheless, please be aware that the information provided by EAPA is for general informational purposes only. It is not intended to constitute legal advice, and it should not in any way be construed as legal advice. EAPA encourages each organization to make its own determination, with assistance from legal counsel, as to whether an SBC is required and, if so, the language to be used in completing it.
The following information is currently available to EAPA members HERE (you must login with your member number to access it). Additional information will be added as it becomes available.
Sample completed SBC form with suggested language for EAPs
Instructions for completing an SBC for EAPs
Blank SBC template as an editable Word document
FAQs concerning requirements for Summary of Benefits and Coverage (SBC) for EAPs
"Legal Lines" EAPs & the Affordable Care Act" by Sandra G. Nye, J.D., MSW, from the 4th Quarter 2012 Journal of Employee Assistance (JEA)
Health Care Overhaul Impact of Disclosure Requirements on EAPs by Puneet Leekha, J.D., from the 1st Quarter 2013 Journal of Employee Assistance (JEA)
Other SBC resources open to anyone include: