The SBC is the short, standard summary every health plan has to hand you.
SBC stands for summary of benefits and coverage. It is a short, standard-format document that lets you compare plans side by side. It is a summary only. The plan document and the summary plan description are the governing documents.
One standard format, so plans can be compared.
Federal rules set the format. Every group health plan and insurer uses the same template, so two SBCs can be read side by side.
What It Shows
Deductible, coinsurance and copays, the out-of-pocket limit, which services are covered and what you pay for each, and the exclusions and limits. To find the notice date for a mid-year change, use our notice deadline calculator.
Coverage Examples
The SBC includes worked examples of common situations, such as having a baby or managing diabetes, showing what the plan would pay and what you would pay. Use them as a rough guide to compare plans, remembering that the examples are illustrations and your own costs depend on your actual care.
Standard Terms
The SBC uses the same defined terms everywhere. A uniform glossary explains them, and you can ask for a paper copy. That consistency lets employees compare plans from different insurers on the same footing, and the glossary helps anyone unfamiliar with insurance terms such as deductible or coinsurance.
Minimum Coverage Statements
It states whether the plan provides minimum essential coverage and whether it meets the minimum value standard. These statements matter for employers because they connect to federal coverage and affordability rules, so review them when you compare plans and ask your adviser or counsel how they apply to you.
Where to Look Things Up
It lists the web address for the provider network, the drug formulary and the glossary, and a contact number for questions. Before enrollment, check that these links work and point to the right plan, since employees will rely on them to check doctors and medications.
A Summary, Not the Contract
It says on its face that it is only a summary. The plan document or certificate controls if the two differ. Keep the full plan document or certificate available too, and tell employees where to find it if they have a detailed question about coverage.
The delivery rules, by moment.
When You Apply or Enroll
With the enrollment materials. If there are no written enrollment materials, no later than the first date you are eligible to enroll.
At Renewal
With the renewal application materials if you must re-enroll. If renewal is automatic, no later than 30 days before the new plan year begins.
If the Plan Changes Mid-Year
A material change that would alter the SBC needs a notice at least 60 days before it takes effect, unless it happens at renewal.
Special Enrollees
If you enroll outside open enrollment, such as after a life event, you get it within 90 days of enrolling, the same clock as the SPD.
Whenever You Ask
On request, within seven business days. The plan can send it on paper or electronically, and it must send paper if you ask for paper.
The Glossary on Request
The uniform glossary is available on request in paper or electronic form, within seven business days.
The plan and the insurer share the duty, and one can cover the other.
The Insurer
For an insured plan the insurer prepares the SBC and gives it to the employer, and can give it to employees as well. Ask your carrier when and in what format it will deliver the SBC so you can pass it on in time, and keep a copy for your files.
The Plan Administrator
The employer, as plan administrator, is on the hook too. If the insurer delivers a timely, complete SBC, that satisfies the plan’s duty. Keep records showing that the insurer’s SBC was delivered on time, since that record is your proof if anyone questions it later. Counsel can confirm what applies to your plan.
Self-Funded Plans
There is no insurer to hand it over, so the plan administrator or its vendor produces and delivers it. An employer that contracts it out should monitor the vendor. Ask the vendor in writing how and when it will deliver SBCs, and check that the content is accurate for each benefit package.
One SBC per Family
A single SBC to the participant at their last known address generally covers the family. A beneficiary at a different address needs a separate copy. Keep the mailing addresses in your enrollment system current, and note any dependents who live elsewhere so they are not missed.
Each Benefit Package
An SBC is needed for each benefit package. Employees are automatically sent the one they are enrolled in, and can ask for the others. If you offer several plans, give employees a simple way to request the others, such as a link in the guide or a contact in HR.
Language and Format
It must be in a culturally and linguistically appropriate form. It cannot run longer than four double-sided pages, and print cannot be smaller than 12-point.
The SBC is not the SPD. See your benefits guide is not your plan document for the plan document side, and reading your plan documents for how the pieces fit.
What employers and employees ask about the SBC.
Is an SBC the same as an SPD?
No. The SBC is a short, standardized comparison tool. The summary plan description is the longer ERISA document that lays out the plan’s terms and your rights.
Is an SBC the same as the benefits guide?
No. A benefits guide is a marketing and enrollment piece. It does not replace an SBC or an SPD.
Who writes the SBC for an insured plan?
The insurer, using the federal template. The employer should check it is the right plan and the right year before it goes out.
What happens if an employer does not provide one?
A willful failure can be fined up to $1,000 for each failure, adjusted for inflation, with each participant a separate offense.
Does the SBC show what I will actually pay?
It shows cost sharing and examples. Your actual cost depends on the claim. The EOB shows what happened to a specific claim. See the EOB guide.
Can CFH help with SBCs?
For the accounts we serve, our team checks that the right SBC is in the enrollment materials each year.
Related reading: Plan document vs benefits guide · Reading your plan documents · Explanation of benefits · Form 5500 and plan documents · SMM and SAR Deadlines for Employer Health Plans
Related reading: Group vs Individual Health Insurance in Michigan
The rules in one place.
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The renewal letter
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