PHP is responsible for creating and delivering the SBC to the Employer Group, at no additional cost to members at renewal or for any mid-year plan change. For self-funded groups, the responsibility of creating the SBCs lies with the employer.
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At the times required by the Affordable Care Act (ACA), including:
- Initial enrollment - at new group implementation and to new hires throughout the year
- Open enrollment - immediately upon confirmation of group’s plan decision for renewal
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The Employer Group is responsible for sending SBCs, either in paper or electronic format, to its employees, participants and beneficiaries. PHP will create the SBCs so that the employer can distribute SBCs to such individuals in a timely manner.
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A short, easy-to-understand document provided to consumers that summarizes the key features of the plan or coverage they are considering or that they currently have. Think of it as the “Nutrition Facts” label of the health insurance industry.
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An employer can be assessed a fine of $1,000 per affected individual where the employer or carrier willfully fails to provide an SBC. Other penalties can include a $100 per day, per affected person fine issued by the Department of Labor or Health and Human Services. PHP will be held harmless from all costs associated if you fail to distribute the SBCs as required by the ACA or other applicable regulations. If PHP is fined in relation to the employer’s failure to abide by any SBC legal requirements, the employer will be liable to reimburse PHP for any resulting fines and/or penalties.
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Upon application - If a plan (including a self-insured group health plan) or an issuer distributes written application materials for enrollment, the SBC must be provided as part of those materials. For this purpose, written application materials include any forms or requests for information, in paper form or through a website or email, that must be completed for enrollment.
By first day of coverage - If there is any change in the information required to be in the SBC that was provided upon application and before the first day of coverage, the plan or issuer must update and provide a current SBC no later than the first day of coverage.
Special enrollment/enrollees - The SBC must be provided to special enrollees no later than the date on which a summary plan description is required to be provided (90 days from enrollment). A special enrollee is an eligible person who did not enroll during their open enrollment period, or a person who acquired a new dependent through marriage, birth or adoption.
Upon renewal - If a plan or issuer requires participants and beneficiaries to actively elect to maintain coverage during an open season, or provides them with the opportunity to change coverage options in an open season, the plan or issuer must provide the SBC at the same time it distributes open season materials.
Upon request - The SBC must be provided upon request for an SBC or summary information about the health coverage as soon as practicable but in no event later than seven business days following receipt of the request.
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Before PHP can revise any SBCs for distribution by the employer group, the group must provide adequate advanced notification to PHP if there will be a change to benefits.
**Members must receive an updated SBC 60 days in advance of any changes to their benefit plan.**
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