FAQS ABOUT AFFORDABLE CARE ACT 
IMPLEMENTATION (PART XIV) 
April 23, 2013 (corrected) 
 
Set out below are additional Frequently Asked Questions (FAQs) regarding implementation of 
various provisions of the Affordable Care Act.  These FAQs have 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.cciio.cms.gov/resources/factsheets/index.html), these FAQs answers questions from 
stakeholders to help people understand the new law 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, 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 February 14, 2012, the Departments published final 
regulations regarding the SBC.1  At the same time, the Departments published a notice 
announcing the availability of templates, instructions, and related materials authorized for 
implementing the disclosure provisions under PHS Act section 2715 for the first year of 
applicability (that is, for SBCs and the uniform glossary provided with respect to coverage 
beginning before January 1, 2014).2   
 
The documents authorized for the first year of applicability do not include language for the 
statement in the SBC (required to be included by PHS Act section 2715(b)(3)(G) and paragraph 
(a)(2)(i)(G) of the final regulations) regarding whether a plan or coverage provides minimum 
essential coverage (MEC) 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 (MV) 
requirements. When the documents authorized for the first year of applicability were first 
released, the Departments stated that updated materials would be issued for later years.3   
 
Q1: What templates should plans and issuers use for the SBCs and the uniform glossary 
required to be provided after the first year of applicability? 
 
An updated SBC template (and sample completed SBC) are now available at http://cciio.cms.gov 
and http://www.dol.gov/ebsa/healthreform.  These documents are authorized for use with respect 
                                                            
1 See 26 CFR 54.9815-2715, 29 CFR 2590.715-2715, and 45 CFR 147.200, published at 77 FR 8668 (February 14, 
2012). 
2 See 77 FR 8706 (February 14, 2012).    
3 See id. at 8707.  See also ACA Implementation FAQs, Part VIII, Q24, available at www.dol.gov/ebsa/faqs/faq-
aca8.html and cciio.cms.gov/resources/factsheets/aca_implementation_faqs8.html. 
1 
  to group health plans and group and individual health insurance coverage for SBCs provided 
with respect to coverage beginning on or after January 1, 2014, and before January 1, 2015 
(referred to in this guidance document as the second year of applicability).   
 
The only change to the SBC template and sample completed SBC is the addition of  
statements of whether the plan or coverage provides MEC (as defined under section 5000A(f) of 
the Internal Revenue Code 1986) and whether the plan or coverage meets the MV requirements 
(that is, the plans or coverages share of the total allowed costs of benefits provided under the 
plan or coverage is not less than 60 percent of such costs).   On page 4 of the SBC template (and 
illustrated on page 6 of the sample completed SBC), a plan or issuer should indicate in the 
designated entry on the SBC template that the plan or coverage does or does not provide 
MEC and whether the plan or coverage does or does not meet applicable MV requirements. 
 
There are no changes to the uniform glossary.  There are also no changes to the Instructions for 
Completing the SBC (for either group or individual health coverage), Why This Matters 
language for the SBC, or to the coverage examples.    
 
Q2: Our plan is already working on the process of preparing SBCs for issuance in the 
second year of applicability and it would be an administrative burden to add the new data 
element to the template at this point in the process.  Is any relief available to provide 
information about MEC and MV without changing the SBC template? 
 
Yes.  To the extent a plan or issuer is unable to modify the SBC template for disclosures required 
to be provided with respect to the second year of applicability, the Departments will not take any 
enforcement action against a plan or issuer for using the template authorized for the first year of 
applicability, provided that the SBC is furnished with a cover letter or similar disclosure stating 
whether the plan or coverage does or does not provide MEC and whether the plans or 
coverages share of the total allowed costs of benefits provided under the plan or coverage does 
or does not meet the MV requirement under the Affordable Care Act.  The language for these 
statements is as follows: 
 
Does this Coverage Provide Minimum Essential Coverage?  
The Affordable Care Act requires most people to have health care coverage that qualifies 
as minimum essential coverage.  This plan or policy [does/does not] provide 
minimum essential coverage.   
 
Does this Coverage Meet the Minimum Value Standard? 
The Affordable Care Act establishes a minimum value standard of benefits of a health 
plan.  The minimum value standard is 60% (actuarial value).  This health coverage 
[does/does not] meet the minimum value standard for the benefits it provides.  
  
 
 
 
 
2 
  Q3: A previous FAQ stated that the Departments intended to make changes to the SBC 
template for 2014 to be consistent with the Affordable Care Acts requirement to eliminate 
all annual limits on essential health benefits.4  Have the Departments made any changes 
related to this requirement? 
 
No.  As stated earlier, the only change to the SBC template and sample completed SBC is the 
addition of information to indicate whether the plan or coverage provides MEC and whether the 
plans or coverages share of the total allowed costs of benefits provided under the plan or 
coverage meets applicable MV requirements under the Affordable Care Act.   
 
Plans and issuers should continue to complete the SBC template consistent with the Instructions 
for Completing the SBC (for either group or individual health coverage, as applicable) for the 
Important Questions chart that appears on page 1 of the SBC: 
 
  In the Answers column, the plan or issuer should respond No, where the template asks, 
Is there an overall annual limit on what the plan pays?, as plans and issuers are 
generally prohibited from imposing annual limits on the dollar value of essential health 
benefits for plan years (in the individual market, policy years) beginning on or after 
January 1, 2014.5 
  In the Why This Matters column, the plan or issuer must show the following language: 
The chart starting on page 2 describes any limits on what the plan will pay for specific 
covered services, such as office visits.6 
 
Additionally, as applicable, plans and issuers should continue to include information regarding 
annual or lifetime dollar limits on specific covered benefits as required in the chart starting on 
page 2 of the SBC (in the Limitations & Exceptions column), as described in the Instructions for 
Completing the SBC (for either group or individual health coverage, as applicable). 
 
To the extent a plan or issuer wishes to modify the SBC template for disclosures required to be 
provided for the second year of applicability to remove this information, the Departments will 
not take any enforcement action against a plan or issuer for removing the entire row in the 
Important Questions chart on page 1 of the SBC (with the question: Is there an overall annual 
limit on what the plan pays?).  
 
 
Q4: A previous FAQ stated that the Departments intended to add additional coverage 
examples for 2014.7  Have the Departments made any changes related to this requirement? 
                                                            
4 See ACA Implementation FAQs Part VIII, Q24, available at http://www.dol.gov/ebsa/faqs/faq-aca8.html and 
http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs8.html. 
5 See 26 CFR 54.9815-2711(a)(2) and (f); 29 CFR 2590.715-2711(a)(2) and (f); and 45 CFR 147.126(a)(2), (d) and 
(f). 
6 The rules of PHS Act section 2711 and its implementing regulations do not prevent a plan or issuer from placing 
annual or lifetime dollar limits on specific covered benefits that are not essential health benefits to the extent that 
such limits are otherwise permitted under applicable Federal or State law.  See 26 CFR 54.9815-2711(b); 29 CFR 
2590.715-2711(b); and 45 CFR 147.126(b); see also section 1302(b) of the Affordable Care Act and its 
implementing regulations at 45 CFR 156.100 et seq.   
3 
   
To help transition to new market changes in 2014, the Departments believe it is prudent to 
maintain the current coverage examples. Additional coverage examples are not required as part 
of the SBC at this time.  As with the SBC authorized for the first year of applicability, the 
documents authorized for the second year of applicability continue to require the same two 
coverage examples authorized for the first year of applicability  having a baby (normal 
delivery) and managing type 2 diabetes (routine maintenance of a well-controlled condition).   
 
Q5: Safe harbors and other enforcement relief were provided by the Departments related 
to the requirement to provide an SBC and a uniform glossary for the first year of 
applicability.  Will this relief be extended? 
 
Yes.  As stated in previous FAQs,8 the Departments basic approach to ACA implementation is: 
[to work] together with employers, issuers, States, providers and other stakeholders to help 
them come into compliance with the new law and [to work] with families and individuals to help 
them understand the new law and benefit from it, as intended. Compliance assistance is a high 
priority for the Departments.  Our approach to implementation is, and will continue to be, 
marked by an emphasis on assisting (rather than imposing penalties on) plans, issuers and others 
that are working diligently and in good faith to understand and come into compliance with the 
new law. In recognition of and to ensure a smooth transition to new market changes in 2014, the 
Departments believe it is prudent to extend the following enforcement relief to apply through the 
end the second year of applicability:  
 
  Affordable Care Act Implementation FAQs Part VIII, Q2 (regarding the Departments 
basic approach to implementation of the SBC requirements during the first year of 
applicability);9 
  Affordable Care Act Implementation FAQs Part IX, Q1 (regarding the circumstances in 
which an SBC may be provided electronically);10 
  Affordable Care Act Implementation FAQs Part IX, Q8 (regarding penalties for failure to 
provide the SBC or uniform glossary);11 
  Affordable Care Act Implementation FAQs Part IX, Q9 (regarding the coverage 
examples calculator);12 and related information related to use of the coverage examples 
calculator;13 
                                                                                                                                                                                                
7 See ACA Implementation FAQs Part VIII, Q24, available at http://www.dol.gov/ebsa/faqs/faq-aca8.html and 
http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs8.html. 
8 See FAQs Part I Q1 (available at www.dol.gov/ebsa/faqs/faq-aca.html and 
cciio.cms.gov/resources/factsheets/aca_implementation_faqs.html); FAQs Part VIII Q2 (available at 
www.dol.gov/ebsa/faqs/faq-aca8.html and cciio.cms.gov/resources/factsheets/aca_implementation_faqs8.html); and 
FAQs Part IX Q8 (available at www.dol.gov/ebsa/faqs/faq-aca9.html and 
http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs9.html).  
9 Available at http://www.dol.gov/ebsa/faqs/faq-aca8.html and 
http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs8.html.   
10 Available at www.dol.gov/ebsa/faqs/faq-aca9.html and 
http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs9.html.   
11 Available at www.dol.gov/ebsa/faqs/faq-aca9.html and 
http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs9.html.   
4 
    Affordable Care Act Implementation FAQs Part IX, Q10 (regarding an issuers 
obligation to provide an SBC with respect to benefits it does not insure);14and 
  Affordable Care Act Implementation FAQs Part IX, Q13 (regarding expatriate 
coverage);15  
 
In addition, the following enforcement relief continues to apply through the second year of 
applicability, consistent with existing guidance: 
 
  The Special Rule contained in the Instruction Guides for Group and Individual 
Coverage;16 
  Affordable Care Act Implementation FAQs Part IX, Q1 (regarding the circumstances in 
which an SBC may be provided electronically);17 and 
  Affordable Care Act Implementation FAQs Part X, Q1 (regarding Medicare 
Advantage).18 
 
Additionally, Affordable Care Act Implementation FAQs Part VIII, Q5 (regarding use of carve-
out arrangements) applies until further guidance is issued.  The relief provided in this 
Affordable Care Act Implementation FAQs Part VIII, Q5 continues to apply, and plans and 
issuers may rely on this relief at least through the end of 2014.   
 
This guidance supersedes any previous subregulatory guidance (including FAQs) stating that 
enforcement relief for the SBC and uniform glossary requirements is limited to the first year of 
applicability. 
 
Q6: A previous FAQ provided an enforcement safe harbor until September 23, 2013 for 
plans and issuers with respect to insurance products that are no longer being offered for 
purchase (closed blocks of business).19  Will this relief be extended? 
                                                                                                                                                                                                
12 Available at www.dol.gov/ebsa/faqs/faq-aca9.html and 
http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs9.html.   
13 See http://cciio.cms.gov/resources/other/index.html#sbcug. 
14 Available at www.dol.gov/ebsa/faqs/faq-aca9.html and 
http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs9.html.   
15 Available at www.dol.gov/ebsa/faqs/faq-aca9.html and 
http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs9.html.  See also FAQs Part XIII, available at 
http://www.dol.gov/ebsa/faqs/faq-aca13.html and 
http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs13.html, which provides broader relief to 
expatriate coverage that is group health insurance, as described therein.  For self-insured expatriate coverage, this 
guidance extends the enforcement relief for the SBC to the second year of applicability. 
16 See What This Plan Covers and What it Costs: Instruction Guide for Group Coverage, February 2012 edition 
(available at http://www.dol.gov/ebsa/pdf/SBCInstructionsGroup.pdf and 
http://cciio.cms.gov/resources/files/Files2/02102012/instructions-group-final.pdf) and What This Plan Covers and 
What it Costs: Instruction Guide for Individual Health Insurance Coverage, February 2012 edition (available at 
http://www.dol.gov/ebsa/pdf/SBCInstructionsIndividual.pdf and 
http://cciio.cms.gov/resources/files/Files2/02102012/instructions-individual-final.pdf). 
17 Available at www.dol.gov/ebsa/faqs/faq-aca9.html and 
http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs9.html.   
18 Available at http://www.dol.gov/ebsa/faqs/faq-aca10.html and 
http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs10.html.   
5 
   
Yes.  The relief provided in this FAQ extends this date to September 23, 2014 for plans and 
issuers with respect to an insured product that meets three conditions:  
 
  The insured product is no longer being actively marketed;  
  The health insurance issuer stopped actively marketing the product prior to September 
23, 2012, when the requirement to provide an SBC was first applicable to health 
insurance issuers; and 
  The health insurance issuer has never provided an SBC with respect to the insured 
product. 
 
That is, if a health insurance product is not being actively marketed and the health insurance 
issuer has not actively marketed the product at any time on or after September 23, 2012, the 
Departments will not take any enforcement action against the plan or issuer for failing to provide 
an SBC before September 23, 2014 with respect to a product, provided the SBC is provided for 
that product no later than September 23, 2014.   
 
However, if an insured product was actively marketed for business on or after September 23, 
2012, and is no longer being actively marketed for business, or if the plan or issuer ever provided 
an SBC in connection with the insured product, the plan and issuer must provide the SBC with 
respect to such coverage, as required by PHS Act section 2715 and the final regulations. 
 
Q7:  The final regulations regarding the SBC included an anti-duplication provision for 
group health coverage clarifying that an entity required to provide an SBC would be 
considered to have satisfied that requirement with respect to an individual if another party 
provides a timely and complete SBC.20  Is a similar anti-duplication rule applicable for 
student health insurance coverage?   
 
Yes.  On March 21, 2012, HHS issued a final rule establishing requirements for student health 
insurance coverage.21  The final rule defines student health insurance coverage as a type of 
individual health insurance coverage provided pursuant to a written agreement between an 
institution of higher education and a health insurance issuer.22  HHS is extending the anti-
duplication rule for group health coverage set forth in the final SBC regulations to student health 
insurance coverage, as defined in in 45 CFR 147.145(a).  Therefore, the requirement to provide 
an SBC with respect to an individual will be considered satisfied for an entity (such as an 
institution of higher education) if another party (such as a health insurance issuer) provides a 
timely and complete SBC to the individual.   
 
                                                                                                                                                                                                
19 See ACA Implementation FAQs Part IX, Q12, available at www.dol.gov/ebsa/faqs/faq-aca9.html and 
http://cciio.cms.gov/resources/factsheets/aca_implementation_faqs9.html. 
20 For example, in the case of a group health plan funded through an insurance policy, the plan satisfies the 
requirement to provide an SBC with respect to an individual if the issuer provides a timely and complete SBC to the 
individual.  See 26 CFR 54.9815-2715(a)(1)(iii)(A); 29 CFR 2590.715-2715(a) (1)(iii)(A); and 45 CFR 147.200(a) 
(1)(iii)(A).   
21 See 45 CFR 147.145, published at 77 FR 16453 (March 21, 2012). 
22 See 45 CFR 147.145(a). 
6