FAQS ABOUT AFFORDABLE CARE ACT 
IMPLEMENTATION PART 41
February 3, 2020 
Set out below are additional Frequently Asked Questions (FAQs) regarding implementation of the 
Affordable Care Act. This FAQ has been prepared jointly by the Departments of Labor, Health and 
Human Services (HHS), and the Treasury (collectively, the Departments). Like previously issued 
FAQs (available at http://www.dol.gov/ebsa/healthreform/ and 
http://www.cms.gov/cciio/resources/fact-sheets-and-faqs/index.html), this FAQ answers questions 
from stakeholders to help people understand the Affordable Care Act and benefit from it, as 
intended. 
Summary of Benefits and Coverage 
Public Health Service (PHS) Act section 2715, as added by the Affordable Care Act and incorporated 
by reference into section 715 of the Employee Retirement Income Security Act and section 9815 of 
the Internal Revenue Code, directs the Departments to develop standards for use by a group health 
plan and a health insurance issuer offering group or individual health insurance coverage in compiling 
and providing a summary of benefits and coverage (SBC) that accurately describes the benefits and 
coverage under the applicable plan or coverage. On November 7, 2019, the updated SBC coverage 
examples calculator (the 2021 Calculator), the Guide and Narratives for coverage examples (the 
2021  Guide  and  Narratives), the  instructions  for  completing  the  SBC  Template  (the  2021 
Instructions), and the SBC Template and associated materials (the 2021 SBC) were  released 
(available at: https://www.dol.gov/agencies/ebsa/laws-and-regulations/laws/affordable-care-act/for-
employers-and-advisers/summary-of-benefits  and  https://www.cms.gov/CCIIO/Resources/Forms-
Reports-and-Other-Resources/index). 
The release modifies the SBC Template and Instructions as authorized for use on and after April 1, 
2017 to update the statement after the Minimum Essential Coverage disclosure, If you dont have 
Minimum Essential Coverage for a month, youll have to make a payment when you file your tax 
return unless you qualify for an exemption from the requirement that you have health coverage for 
that month. The new statement reads Minimum Essential Coverage generally includes plans, 
health insurance available through the Marketplace or other individual market policies, certain 
Medicare and Medicaid coverage, CHIP, TRICARE, and certain other coverage. If you are eligible 
for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax 
credit. This statement is being updated because, starting January 1, 2019, the tax payment required 
for not having Minimum Essential Coverage or a coverage exemption was reduced to zero. The 
Uniform Glossary is updated as well to remove the definition of Individual Responsibility 
Requirement and update the definition of Minimum Essential Coverage to reflect this change.  
The SBC Template and Instructions have also been updated to include an additional option for 
issuers completing the Minimum Value disclosure on the SBC. As clarified in the Final 2019 Letter  to Issuers in the Federally-facilitated Marketplace,1 the concept of minimum value is not relevant 
with respect to individual market coverage. Thus, the 2021 SBC Template adds Not Applicable as 
a response option for the Minimum Value disclosure, such that the disclosure reads: Does this plan 
meet the Minimum Value Standards? [Yes/No/Not Applicable]. The 2021 Instructions indicate 
that issuers of individual market coverage should answer Not Applicable. The update also adds 
the Total Example Costs for each of the three coverage examples to the template.  
The release also updates the versions of the Calculator, Guides, and Narratives that were authorized 
for use on and after April 1, 2017 in a number of ways. The 2021 Calculator and 2021 Guide and 
Narratives replace 2013 Truven Health MarketScan data with 2016 data, update some of the 
treatment protocols for the SBC medical scenarios, and update the Calculators logic to better align 
its underlying assumptions with how most plans and issuers apply cost sharing rules. A complete list 
of  updates  to  the  Calculator,  Guide,  and  Narratives  is  available  at: 
https://www.cms.gov/CCIIO/Resources/Forms-Reports-and-Other-
Resources/Downloads/Crosswalk-of-Changes-11-2019.pdf.  
Q1. What is the intended implementation date for SBCs using the new template and associated 
documents? 
Group health plans and health insurance issuers of individual and group market coverage will be 
required to use the 2021 SBC, 2021 Instructions, 2021 Guide and Narratives, and, should they choose 
to use the Calculator, the 2021 Calculator, beginning on the first day of the first open enrollment period 
for any plan years (or, in the individual market, policy years) that begin on or after January 1, 2021, 
with respect to coverage for plan or policy years beginning on or after that date.  
Q2. Are plans and issuers required to use the updated Calculator? 
No. Use of the Calculator is not required. The Calculator was developed by HHS, in consultation with 
the Departments of Labor and the Treasury, for group health plans and health insurance issuers to use 
as a tool to generate the estimated out-of-pocket costs that a consumer can expect to pay under the 
plan or coverage for three hypothetical medical scenarios: maternity care, type II diabetes, and a 
simple foot fracture.  
Plans and issuers may create their own calculator using the Guide and Narratives provided by HHS, 
or modify the logic of the Calculator to provide their own method of calculating estimated out-of-
pocket-costs for the coverage examples, which may be more accurate based on their particular plan 
or policy design. The Calculator makes several assumptions that may not be accurate for all plan or 
policy designs. Affordable Care Act Implementation FAQs Part IX Q92 announced a Calculator 
provided by HHS for the completion of the coverage examples, along with a safe harbor for plans 
and issuers that use the Calculator for the first year of applicability for the SBC requirements. 
1 Available at: https://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2019-Letter-
to-Issuers.pdf. 
2 Affordable Care Act Implementation FAQs Part IX, Q9 at https://www.cms.gov/cciio/resources/fact-sheets-
and-faqs/aca_implementation_faqs9.html and https://www.dol.gov/sites/default/files/ebsa/about-ebsa/our-
activities/resource-center/faqs/aca-part-ix.pdf.  Affordable Care Act Implementation FAQs Part XIX, Q83 stated that this safe harbor will continue 
to be in effect until further guidance is issued. To date, no such further guidance on the Calculator 
has been issued. Therefore, plans and issuers may continue to use the Calculator, even where it 
would be possible to develop a more accurate method for generating coverage examples, including 
applicable cost sharing, for the benefit design for which the plan or issuer is creating an SBC. 
3 Affordable Care Act Implementation FAQs Part XIX, Q8 at https://www.cms.gov/cciio/resources/fact-
sheets-and-faqs/aca_implementation_faqs19.html and https://www.dol.gov/sites/default/files/ebsa/about-
ebsa/our-activities/resource-center/faqs/aca-part-xix.pdf.