Summary of Benefits and Coverage and the Uniform Glossary Subregulatory Guidance

DEPARTMENT OF THE TREASURY
Internal Revenue Service
26 CFR Part 54
DEPARTMENT OF LABOR
Employee Benefits Security Administration
29 CFR Part 2590
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CMS-9982-NC
45 CFR Part 147
Summary of Benefits and Coverage and Uniform Glossary – Templates,
Instructions, and Related Materials under the Public Health Service Act
AGENCIES: Internal Revenue Service, Department of the Treasury; Employee Benefits
Security Administration, Department of Labor; Centers for Medicare & Medicaid
Services, Department of Health and Human Services.
ACTION: Solicitation of Comments.

SUMMARY: The Departments of the Health and Human Services, Labor, and the
Treasury (the Departments) are simultaneously publishing in the Federal Register this
document and proposed regulations (2011 proposed regulations) under the Patient
Protection and Affordable Care Act to implement the disclosure for group health plans
and health insurance issuers of the summary of benefits and coverage (SBC) and the
uniform glossary. This document proposes a template for an SBC; instructions, sample
language, and a guide for coverage examples calculations to be used in completing the

template; and a uniform glossary that would satisfy the disclosure requirements under
section 2715 of the Public Health Service (PHS) Act. Comments are invited on these
materials.
COMMENT DATES: Comments are due on or before [INSERT DATE 60 DAYS
AFTER PUBLICATION IN FEDERAL REGISTER].
ADDRESSES: Written comments may be submitted to any of the addresses
specified below. Any comment that is submitted to any Department will be shared with
the other Departments. Please do not submit duplicates.
All comments will be made available to the public. WARNING: Do not include
any personally identifiable information (such as name, address, or other contact
information) or confidential business information that you do not want publicly disclosed.
All comments are posted on the Internet exactly as received, and can be retrieved by most
Internet search engines. No deletions, modifications, or redactions will be made to the
comments received, as they are public records. Comments may be submitted
anonymously.
Department of Labor. Comments to the Department of Labor, identified by RIN
1210-AB52, by one of the following methods:
● Federal eRulemaking Portal: http://www.regulations.gov. Follow the
instructions for submitting comments.
● Email: E-OHPSCA2715.EBSA@dol.gov.
● Mail or Hand Delivery: Office of Health Plan Standards and Compliance
Assistance, Employee Benefits Security Administration, Room N-5653, U.S. Department

2

of Labor, 200 Constitution Avenue NW, Washington, DC 20210, Attention: RIN 1210—
AB52.
Comments received by the Department of Labor will be posted without change to
http://www.regulations.gov and http://www.dol.gov/ebsa, and available for public
inspection at the Public Disclosure Room, N-1513, Employee Benefits Security
Administration, 200 Constitution Avenue, NW, Washington, DC 20210.
Department of Health and Human Services. In commenting, please refer to file
code CMS-9982-NC. Because of staff and resource limitations, we cannot accept
comments by facsimile (FAX) transmission.
You may submit comments in one of four ways (please choose only one of the ways
listed):
1. Electronically. You may submit electronic comments on this regulation to
http://www.regulations.gov. Follow the instructions under the “More Search Options”
tab.
2. By regular mail. You may mail written comments to the following address
ONLY:
Centers for Medicare & Medicaid Services
Department of Health and Human Services,
Attention: CMS-9982-NC,
P.O. Box 8016,
Baltimore, MD 21244-1850.
Please allow sufficient time for mailed comments to be received before the
close of the comment period.

3

3. By express or overnight mail. You may send written comments to the
following address ONLY:
Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Attention: CMS-9982-NC,
Mail Stop C4-26-05,
7500 Security Boulevard,
Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or courier) your
written comments before the close of the comment period to either of the following
addresses:
a. For delivery in Washington, DC-Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
Room 445-G, Hubert H. Humphrey Building,
200 Independence Avenue, SW,
Washington, DC 20201
(Because access to the interior of the Hubert H. Humphrey Building is not
readily available to persons without Federal government identification, commenters are
encouraged to leave their comments in the CMS drop slots located in the main lobby of
the building. A stamp-in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being filed.)
b. For delivery in Baltimore, MD--

4

Centers for Medicare & Medicaid Services,
Department of Health and Human Services,
7500 Security Boulevard,
Baltimore, MD 21244-1850
If you intend to deliver your comments to the Baltimore address, please call
(410) 786-9994 in advance to schedule your arrival with one of our staff members.
Comments mailed to the addresses indicated as appropriate for hand or courier
delivery may be delayed and received after the comment period.
Submission of comments on paperwork requirements. You may submit
comments on this document’s paperwork requirements by following the instructions at
the end of the “Collection of Information Requirements” section in this document.
Inspection of Public Comments: All comments received before the close of the
comment period are available for viewing by the public, including any personally
identifiable or confidential business information that is included in a comment. We post
all comments received before the close of the comment period on the following website
as soon as possible after they have been received: http://www.regulations.gov. Follow
the search instructions on that Web site to view public comments.
Comments received timely will also be available for public inspection as they are
received, generally beginning approximately three weeks after publication of a document,
at the headquarters of the Centers for Medicare & Medicaid Services, 7500 Security
Boulevard, Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. EST. To schedule an appointment to view public comments, phone 1-800743-3951.

5

Internal Revenue Service. Comments to the IRS, identified by REG-140038-10,
by one of the following methods:
● Federal eRulemaking Portal: http://www.regulations.gov. Follow the
instructions for submitting comments.
● Mail: CC:PA:LPD:PR (REG-140038-10), room 5205, Internal Revenue
Service, P.O. Box 7604, Ben Franklin Station, Washington, DC 20044.
● Hand or courier delivery: Monday through Friday between the hours of 8
a.m. and 4 p.m. to: CC:PA:LPD:PR (REG-140038-10), Courier’s Desk, Internal Revenue
Service, 1111 Constitution Avenue, NW, Washington DC 20224.
All submissions to the IRS will be open to public inspection and copying in room
1621, 1111 Constitution Avenue, NW, Washington, DC from 9 a.m. to 4 p.m.
FOR FURTHER INFORMATION CONTACT: Amy Turner or Heather Raeburn,
Employee Benefits Security Administration, Department of Labor, at (202) 693-8335;
Karen Levin, Internal Revenue Service, Department of the Treasury, at (202) 622-6080;
Jennifer Libster or Padma Shah, Centers for Medicare & Medicaid Services, Department
of Health and Human Services, at (301) 492-4252.
CUSTOMER SERVICE INFORMATION: Individuals interested in obtaining
information from the Department of Labor concerning employment-based health
coverage laws may call the EBSA Toll-Free Hotline at 1-866-444-EBSA (3272) or visit
the Department of Labor’s website (http://www.dol.gov/ebsa). In addition, information
from HHS on private health insurance for consumers can be found on the Centers for
Medicare & Medicaid Services (CMS) website

6

(http://www.cms.hhs.gov/HealthInsReformforConsume/01_Overview.asp) and
information on health reform can be found at http://www.healthcare.gov.
SUPPLEMENTARY INFORMATION:
I.

Introduction
The Departments of Health and Human Services (HHS), Labor, and the Treasury

(the Departments) are taking a phased approach to issuing regulations and guidance
implementing the revised Public Health Service Act (PHS Act) sections 2701 through
2719A and related provisions of the Patient Protection and Affordable Care Act
(Affordable Care Act).1 Section 2715 of the PHS Act directs the Departments to develop
standards for use by a group health plan and a health insurance issuer in compiling and
providing a summary of benefits and coverage (SBC) that “accurately describes the
benefits and coverage under the applicable plan or coverage.” Section 2715 of the PHS
Act also directs the Departments to provide for the development of a uniform glossary.
The statute directs the Departments, in developing such standards, to “consult with the
National Association of Insurance Commissioners” (referred to in this document as the
“NAIC”), “a working group composed of representatives of health insurance-related
consumer advocacy organizations, health insurance issuers, health care professionals,
patient advocates including those representing individuals with limited English
proficiency, and other qualified individuals.”

1

The Affordable Care Act also adds section 715(a)(1) to the Employee Retirement Income Security Act
(ERISA) and section 9815(a)(1) to the Internal Revenue Code (the Code) to incorporate the provisions of
part A of title XXVII of the PHS Act into ERISA and the Code, and make them applicable to group health
plans, and health insurance issuers providing health insurance coverage in connection with group health
plans.

7

As part of this required consultation, the NAIC convened the Consumer
Information (B) Subgroup (NAIC working group), comprised of a diverse group of
stakeholders.2 This working group met frequently each month for over one year while
developing its recommendations. The NAIC working group created two subgroups -one focused on developing a uniform glossary of health insurance and medical terms and
the other focused on developing standards for the SBC. All drafts were discussed and
agreed to by the entire NAIC working group and then submitted to the full NAIC
membership for a vote to submit the drafts as recommendations to the Departments.
Throughout the process, NAIC working group draft documents and meeting notes were
displayed on the NAIC’s website for public review, and several interested parties filed
formal comments. In addition to participation from the NAIC working group members,
conference calls and in-person meetings were open to other interested parties and
individuals and provided an opportunity for non-member feedback. The NAIC indicates
that stakeholders from a diverse pool of backgrounds participated in working group
conference calls.3
As a result of this process, the NAIC working group recommended use of a
uniform SBC template, as well as a uniform glossary, for the individual and group
insurance markets. In developing these recommendations, the draft SBC template,
including the coverage examples, and the draft uniform glossary underwent consumer

2

A list of the NAIC working group members can be found at:
http://www.naic.org/documents/committees_b_consumer_information_contacts.pdf.
3
Records and other information relating to all of the meetings held by the NAIC working group can be
found at: http://www.naic.org/committees_b_consumer_information.htm.

8

testing,4 sponsored by both consumer and insurance industry groups. These tests were
intended to assist in determining necessary adjustments to ensure the final product was
consumer friendly.5 The Departments have received transmittals from the NAIC that
include a recommended template for the SBC (referred to in this document as the “SBC
template”)6 with instructions, samples, and a guide for coverage examples calculations to
be used in completing the SBC template. The NAIC transmittals also included a
recommended uniform glossary of coverage and medical terms (referred to in this
document as the “uniform glossary”). The SBC template and uniform glossary include
modifications made by the NAIC working group in response to the results of extensive
consumer testing.
The 2011 proposed regulations and this document follow the recommendations
made by the NAIC and incorporate the documents drafted by the NAIC, including the
SBC template (with instructions, sample language, and a guide for coverage examples
calculations to be used in completing the SBC template) and the uniform glossary. The

4

The NAIC consulted readability experts and conducted consumer testing. The SBC format was designed
to enhance to consumer understanding and usability. For example, use of vocabulary, such as “don’t”
verses “do not” reflects intentional design based on feedback from consumer testing. These format choices
reflect in part, the NAIC’s efforts to address the statutory requirement that the form be "culturally and
linguistically appropriate."
5
Summaries of this consumer testing are available at:
http://www.naic.org/documents/committees_b_consumer_information_101012_ahip_focus_group_summar
y.pdf;
http://www.naic.org/documents/committees_b_consumer_information_110603_ahip_bcbsa_consumer_test
ing.pdf;
http://www.naic.org/documents/committees_b_consumer_information_101014_consumers_union.pdf (a
more detailed summary of which is accessible at:
http://prescriptionforchange.org/pdf/CU_Consumer_Testing_Report_Dec_2010.pdf); and
http://www.naic.org/documents/committees_b_consumer_information_110603_consumers_union_testing.p
df.
6

In their materials, the NAIC uses the phrase "Summary of Coverage" to describe the SBC template.
However, the Departments use the term "Summary of Benefits and Coverage" in the proposed regulations
and this document. Both of these terms are meant to refer to the same document (located in Appendix A-1
of this document).

9

Appendices do not include a sample coverage example calculation for breast cancer in
the individual market that was transmitted by the NAIC. Upon review, it appeared that
some of the data in the example might be subject to copyright protection. Moreover, the
sample coverage example calculation provided by the NAIC was limited to breast cancer
in the individual market and did not address the other two coverage examples – maternity
coverage and diabetes. Finally, particular coding information and pricing information
included in the sample would change annually, which would result in the data included in
the sample becoming outdated relatively quickly. Accordingly, HHS is publishing on its
website (at http://cciio.cms.gov) the coding and pricing information necessary to perform
coverage example calculations for all three coverage examples. HHS will update this
information annually.
Instead of proposing possible changes to the NAIC’s proposed SBC template and
related materials at this time, this document proposes to incorporate the NAIC working
group’s recommended materials as transmitted (with the exception of the sample
coverage example, explained above), and invites public comment. The Departments
recognize that changes to the SBC template may be appropriate to accommodate various
types of plan and coverage designs, to provide additional information to individuals, or to
improve the efficacy of the disclosures recommended by the NAIC. In addition, the
SBC template and related documents were drafted by the NAIC primarily for use by
health insurance issuers.7 The NAIC states in its transmittal letter that additional
modifications may be needed for some group health plans. Consequently, comments are

7

National Association of Insurance Commissioners, Consumer Information Working Group, December 17,
2010 Letter to the Secretaries. Available at
http://www.naic.org/documents/committees_b_consumer_information_ppaca_letter_to_sebelius.pdf.

10

requested on these issues specifically and on the SBC template, sample completed SBC,
instructions for both group health plan coverage and individual health insurance
coverage, sample language for the “Why this Matters” section of the SBC, guide for
coverage examples calculations, and on the uniform glossary generally. After the public
comment period, the Departments will finalize these documents. Consistent with PHS
Act section 2715(c), the Departments will periodically review and update these
documents as appropriate, taking into account public comments.
II.

Proposal
This document proposes an SBC template (with instructions, samples, and a guide

for coverage examples calculations to be used in completing the SBC template), and the
uniform glossary, to comply with the disclosure requirements of PHS Act section 2715,
as authorized by the Departments pursuant to paragraph (a)(4) of the 2011 proposed
regulations. The SBC template, sample completed SBC, instructions for both group
health plan coverage and individual health insurance coverage, sample language for the
“Why This Matters” section of the SBC, guide for coverage examples calculations, and
uniform glossary are identical to the documents transmitted by the NAIC. These items
are contained in the Appendices to this document.
In addition to the materials in the Appendices that are proposed in this document,
HHS is providing (at http://cciio.cms.gov) the specific information necessary to simulate
benefits covered under the plan or policy for the coverage examples portion of the SBC
(including specific medical items and services, dates of service, billing codes, and
allowed charges for each claim in the three specified benefits scenarios). HHS will
update this information annually on its website. The Departments propose that plans and

11

issuers are not required to update their coverage examples for SBCs provided before the
date that is 90 days after the date that HHS provides this updated information. That is, 90
days after HHS updates the information, SBCs that are otherwise required to be provided
under paragraph (a) of the proposed rules should take into account the new information
when providing coverage examples. For example, if HHS releases updated information
on September 15 of a year, SBCs required to be provided on or after December 14 of that
year under the rules of paragraph (a) of the proposed rules would need to include
coverage examples calculated using the new information. However, these updates alone
will not be considered a material modification under paragraph (b) of the 2011 proposed
regulations. Comments are invited on this information as well, including the annual
update provision. The preamble to the 2011 proposed regulations contains a request for
comment regarding various approaches to providing the coverage examples. Commenters
addressing the requirement to provide updated coverage examples are encouraged to
consider how updates would be made to the coverage examples under these various
approaches and what additional instructions should be added to address updates and a
possible phased-in approach to implementation discussed in the preamble to the 2011
proposed regulations.
With respect to the element of the SBC regarding a statement about whether a
plan or coverage provides minimum essential coverage (as defined under section
5000A(f) of the Code) and whether the plan’s or coverage’s share of the total allowed
costs of benefits provided under the plan or coverage meets applicable minimum value

12

requirements (minimum essential coverage statement),8 because this content is not
relevant until other elements of the Affordable Care Act are implemented, this statement
is not in the NAIC recommendations. For the same reason, and as discussed more fully
in the preamble to the 2011 proposed regulations, the minimum essential coverage
statement is not required to be in the SBC until the plan or coverage is required to
provide an SBC with respect to coverage beginning on or after January 1, 2014. As
provided in the preamble to the 2011 proposed regulations, comments are requested on
how employers might provide the information included in the minimum essential
coverage statement and other plan-level reporting in a manner that minimizes duplication
and burden.
In addition, the SBC template recommended by the NAIC and located in
Appendix A-1 of this document includes websites for individuals to access the uniform
glossary, for information about prescription drug coverage, and for information about the
plan or coverage provider network. The Departments note, however, these websites are
not working websites. Plans and issuers would need to modify this aspect of the SBC
template to include relevant, working web addresses (for the uniform glossary, this may
be the web address of either the Department of Labor or HHS website, or on the plan’s or
issuer’s own website). The Departments invite comment on whether this statement in the
SBC template regarding the electronically available uniform glossary should be modified
to include a statement that the uniform glossary is available in paper form upon request.
III.

Solicitation of Comments

8

PHS Act section 2715(b)(3)(G) provides that this statement must indicate whether the plan or coverage
(1) provides minimum essential coverage (as defined under section 5000A(f) of the Code) and (2) ensures
that the plan’s or coverage’s share of the total allowed costs of benefits provided under the plan or coverage
is not less than 60 percent of such costs.

13

The Departments solicit comments generally on the SBC template and related
documents and the uniform glossary included in the Appendices, as well as on specific
issues set forth below (including on what modifications, if any, are needed for group
health plans to use the SBC template).
The NAIC stated in the December 2010 transmittal letter that the working group
intentionally designed the layout and color of the SBC template based on consumer
testing to make the document more readable and to facilitate comparison of different plan
and coverage options. The Departments recognize, however, that color printing may be
costly for some plans and issuers and therefore propose that a plan or issuer will be
compliant if it uses either the color version (available on the websites of the Departments
of Labor and HHS),9 as recommended by the NAIC, or the grayscale version (included in
the Appendices to this document). In addition, the Departments note that while the
NAIC-recommended SBC template is only three double-sided pages, the Departments are
proposing that a completed SBC may be four double-sided pages in length. The SBC
template reserves space to ensure that a plan or issuer with different benefit designs (such
as multiple, tiered provider networks) could provide all the necessary information, and
that additional coverage examples could be added in the future, within four double-sided
pages. (See the preamble to the 2011 proposed regulations for a request for comment
regarding various approaches to providing the coverage examples.)
The Departments are interested in any general comments regarding the proposed
SBC template, sample completed SBC, instructions for both group health plan coverage
and individual health insurance coverage, sample language for the “Why This Matters”
9

See www.dol.gov/ebsa or cciio.cms.gov.

14

section of the SBC, guide for coverage examples calculations, and uniform glossary. In
making this request for comment, the Departments note that the purpose of PHS Act
section 2715 is to provide individuals and plan participants with a brief summary of plan
or policy benefits and coverage so that they may more easily compare health care
coverage and better understand the terms of coverage (or exceptions to the coverage).
The SBC is intended to assist individuals purchasing coverage in the individual market in
comparing the benefits and coverage of different individual policies offered by insurance
issuers. Likewise, the SBC is intended to assist employees who are offered group
coverage to compare among different employer-provided health care options or to
compare their employer’s options with other coverage for which they may be eligible,
such as a spouse’s or dependent’s offer of employer-provided health care coverage, a
former employer’s COBRA continuation coverage,10 or a policy on the individual
market.
In order to make it as easy as possible for individuals to understand the terms of their
own coverage and compare coverage and benefits efficiently and accurately, the statute
provides for, and the NAIC recognized the importance of, presenting the SBC in a
uniform format. We invite comments on how this statutory requirement should be
applied, including the nature and extent of the uniformity that should be required in the
specific language of the SBC and the manner and sequence in which the information in
the SBC is presented. We ask that any comments proposing that flexibility be permitted
in aspects of the presentation of the SBC explicitly address the potential positive or

10

As defined in 26 CFR 54.9801-2, 29 CFR 2590.701-2, and 45 CFR 144.103, COBRA means Title X of
the Consolidated Omnibus Budget Reconciliation Act of 1985, as amended.

15

negative effects on individuals’ ability to effectively compare benefits and coverage
among and across individual policies and group health plans.
The Departments also invite comments on the following specific issues:
1. The SBC template is intended to be used by all types of plan or coverage designs.
The Departments are interested in comments related to issues that may arise from
the use of this template for different types of plan or coverage designs (for
example, designs using tiered provider networks or group health plans that may
use multiple issuers or service providers to provide or administer different
categories of benefits within a benefit package).
2. The Departments are interested in comments regarding any modifications needed
for use by group health plans (e.g., with respect to disclosure regarding cost of
coverage and changes in terminology required for self-insured plans, such as use
of the term “plan year” instead of “policy period”).
3. The Departments are interested in comments regarding whether the content of the
SBC should require inclusion of additional information, such as information
regarding any preexisting condition exclusion under the plan or policy, 11 status as
a grandfathered health plan, 12 or other information that might be important for
individuals to know about their coverage and how the SBC template could be

11

Note: The general notice of preexisting condition exclusion and the individual notice of preexisting
condition exclusion at 26 CFR 54.9801-3(c) and (e), 29 CFR 2590.701-3(c) and (e), and 45 CFR
146.111(c) and (e), were published as part of the Departments’ HIPAA portability regulations on December
30, 2004, 69 FR 78720.
12
Note: Under paragraph (a)(2) of the Departments’ interim final regulations regarding status as a
grandfathered health plan, to maintain grandfather status, group health plans and health insurance coverage
must include a statement in any plan materials describing the benefits provided that the plan or coverage
believes it is a grandfathered health plan. Model language is provided. See 26 CFR 54.9815-1251T(a)(2),
29 CFR 2590.715-1251(a)(2), and 45 CFR 147.140(a)(2), published in the Federal Register on June 17,
2010, 75 FR 34538.

16

modified to ensure effective disclosure of these additional elements, while
respecting the statutory formatting requirements. For example, comments are
requested on whether a simplified reporting method, such as a checkbox, could be
used to disclose preexisting condition exclusions and grandfather status.
4. The fourth page of the SBC template includes a list of services that plans and
issuers must indicate as either excluded or covered in the “Excluded Services &
Other Covered Services” chart. The Departments solicit comments on whether
services should be added or removed from this list, as well as whether the
disclosure stating that the list is not complete is adequate.
5. The SBC template includes a disclosure on the first page indicating to consumers
that the SBC is not the actual policy and does not include all of the coverage
details found in the actual policy. The Departments solicit comments on whether
this disclosure is adequate.
The uniform glossary is also included in Appendix E of this document. The
Departments propose that plans and issuers cannot make any modifications to this
glossary. The uniform glossary was developed to facilitate and enhance consumer
comprehension and is not intended to provide legal or contractual definitions that
necessarily apply accurately, without modification, to every plan or coverage. The NAIC
consumer testing found that certain terms relating to cost-sharing provisions were
particularly difficult for consumers to understand. As a result, the NAIC developed
diagrams to accompany the textual definitions of these terms. The Departments solicit
comments on the uniform glossary, including its terms and definitions, and whether other

17

terms should be added to the glossary, as well as whether any of the terms would be
considered inaccurate or misleading based on a particular plan or coverage design.
Comments are also invited on the standards set forth in the 2011 proposed
regulations. To comment on the 2011 proposed regulations, see the comment section of
the 2011 proposed regulations, published elsewhere in this issue of the Federal Register.
IV.

Paperwork Reduction Act
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13) (PRA), no

persons are required to respond to a collection of information unless such collection
displays a valid OMB control number. The Department notes that a Federal agency
cannot conduct or sponsor a collection of information unless it is approved by OMB
under the PRA, and displays a currently valid OMB control number, and the public is not
required to respond to a collection of information unless it displays a currently valid
OMB control number. See 44 U.S.C. 3507. Also, notwithstanding any other provisions of
law, no person shall be subject to penalty for failing to comply with a collection of
information if the collection of information does not display a currently valid OMB
control number. See 44 U.S.C. 3512.
This document relates to the information collection request (ICR) contained in a
proposed regulation titled “Summary of Benefits and Coverage and the Uniform
Glossary,” which is published elsewhere in today’s issue of the Federal Register. For a
discussion of the hour and cost burden associated with the ICR, please see the notice of
proposed rulemaking.

18

Sarah Hall Ingram
Acting Deputy Commissioner for Services and
Enforcement,
Internal Revenue Service.

Signed this _15th_______ day of ___________August_______________, 2011.

Phyllis C. Borzi
Assistant Secretary
Employee Benefits Security Administration
Department of Labor

CMS-9982-NC

Dated: July 28, 2011
_____________________________________
Donald Berwick,
Administrator,
Centers for Medicare & Medicaid Services.

Dated: August 9, 2011

________________________________________
Kathleen Sebelius,
Secretary,
Department of Health and Human Services.

BILLING CODE 4120-01-P

V.

Appendices
Table of Contents
A. Summary of Benefits and Coverage (SBC)
Appendix A-1. SBC Template
Appendix A-2. Sample Completed SBC (Individual Health Insurance
Coverage)
B. Instructions for Completing the SBC
Appendix B-1. Instructions – Group Health Plan Coverage
Appendix B-2. Instructions – Individual Health Insurance Coverage
C. Sample Language – Why This Matters section of SBC (Page 1)
Appendix C-1. Why This Matters language for “Yes” Answers
Appendix C-2. Why This Matters language for “No” Answers
D. Coverage Examples Calculations
Appendix D. Guide for Coverage Examples Calculations
E. Uniform Glossary
Appendix E. Uniform Glossary of Coverage and Medical Terms

Overview of Appendices
As stated earlier in this document, the NAIC transmitted the work of the NAIC
Working Group to the Departments. The Appendices to this document include the SBC
documents drafted by the NAIC in their entirety, with the exception of the sample
coverage example calculation for breast cancer in the individual market, as explained
earlier in this document.
Appendix A-1 contains an SBC template, as developed by the NAIC Working
Group. The NAIC Working Group incorporated all of their recommendations contained
in the multiple transmittals to the Departments over the last several months in their final
recommended SBC template.
Appendix A-2 contains a sample completed SBC, using information for a sample
individual health insurance policy. While the sample completed SBC may not align
perfectly with the instructions in every way, the document is useful in providing a general
illustration of a completed SBC for a sample insurance policy.
Appendices B-1 and B-2 contain instructions for group health coverage and
individual health insurance coverage, respectively, to use in completing the SBC
template. The Departments are publishing the sample completed SBC and the
instructions to facilitate compliance with the requirements of the 2011 proposed
regulations and this document.
The SBC instructions include language that must be used when completing the
"Why This Matters" column on the first page of the SBC template. Depending on the
design of the policy or plan, there are two language options provided in Appendices C-1
(for when the answer in the applicable row is "yes") and C-2 (for when the answer in the

applicable row is "no"). Appendices C-1 and C-2 provide an example of how this
column will look when populated with the required language, as applicable depending
upon the terms of the plan or coverage.
Appendix D contains a guide for use by a plan or issuer in compiling information
related to the coverage examples. This document, together with information provided in
Microsoft Excel format by HHS at http://cciio.cms.gov, comprises all the information
necessary to perform coverage example calculations for all three coverage examples.
HHS will update the information on its website annually. With respect to these annual
updates, the Departments propose that 90 days after HHS updates the information, SBCs
that are otherwise required to be provided under paragraph (a) of the 2011 proposed rules
would take into account the new information when providing coverage examples.
Finally, Appendix E contains the Uniform Glossary of Health Insurance and
Medical Terms.
The Departments invite comments on all of the documents in the Appendices to
this document and their use in relation to the requirements of the 2011 proposed
regulations and this document.

Appendix A-1

Summary of Benefits and Coverage (SBC) Template

Appendix A-2

Sample Completed SBC (Individual Health Insurance Coverage)

Appendix B-1

Instructions– Group Health Plan Coverage

Appendix B-2
Coverage

Instructions– Individual Health Insurance

Appendix C-1

Why This Matters language for “Yes” Answers

Appendix C-2

Why This Matters language for “No” Answers

Appendix D

Guide for Coverage Examples Calculations

Appendix E

Uniform Glossary of Coverage and Medical Terms

[FR Doc. 2011-21192 Filed 08/17/2011 at 11:15 am; Publication Date: 08/22/2011]