NAHUThis morning, the Internal Revenue Service (IRS) made an announcement that may affect your clients regarding compliance to new Affordable Care Act (ACA) mandated coverage reports (6055 and 6056) for 2015. The IRS announced that it is giving employers additional time to file certain reports. In Notice 2016-4, the IRS stated that it is delaying filing deadlines after determining that “additional time to adapt and implement systems to gather, analyze, and report this information” was needed by employers, insurers, and other providers.

The deadline for employers to electronically file 1094 forms for 2015 was extended by three months from March 31, 2016, to June 30, 2016. The deadline for filing by paper was also extended by three months from February 29, 2016, to May 31, 2016. Additionally, the deadline for providing employees with 1095 forms for 2015 was extended from February 1, 2016, to March 31, 2016.

Click here for today’s IRS announcement or for background about the mandated ACA coverage reports.

Just what is this “Summary of Benefits & Coverage” that I am required to submit to my employees come September?

The Affordable Care Act (ACA) requires all group health plans, including grandfathered plans and self-insured plans, to provide participants and beneficiaries a summary of benefits and coverage (SBC). The effective date for compliance with the SBC requirements under the ACA was delayed pending further guidance (proposed regulations had been issued in August 2011). The Departments of Labor, Treasury and Health and Human Services (the Departments) issued final rules regarding these provisions which will take effect beginning in September 2012.


Who Must Provide an SBC?

For fully-insured plans, both the carrier and the plan administrator (typically the employer) are responsible for providing the SBC to participants and beneficiaries. The final regulations provide that as long as either one of them provides a complete SBC in a timely manner, the requirement will be deemed satisfied for the other party. Employers should reach out to their carriers to discuss who will take on this responsibility. For self-insured plans, the plan administrator is responsible to provide the SBC and employers should contact their third-party administrator for assistance. The final regulations clarify that a single SBC may be provided to a participant and any beneficiaries at the participant’s last known address. If a beneficiary’s last known address is different than the participant’s, a separate SBC must be furnished to such address.

What is Required to be in the SBC?

  • The following information must be included in the SBC:
  • Uniform definition of standard insurance terms and medical terms;
  • Description of the coverage, including cost sharing for each category of benefits;
  • Exceptions, reductions and limitations of coverage;
  • Cost sharing provisions including deductibles, coinsurance and copay obligations;
  • Renewability and continuation of coverage provisions;
  • Coverage examples;
  • Statement that the SBC is only a summary and that the plan document, policy or certificate of insurance should be consulted;
  • Contact information for questions and to obtain the plan document, policy or certificate of insurance;
  • Internet address to obtain a list of network providers;
  • If the plan has a prescription drug formulary, an internet address to obtain information on prescription drug coverage; and
  • Internet address to review the uniform glossary, and a statement that paper copies are available, as well as contact information for how to get them.

Helpful Links

Compliance Guide:

Summary of Benefits and Coverage Template:

Instructions for Completing the SBC – Group Plans:

Uniform Glossary of Coverage and Medical Terms: