Summary of Benefits and Coverage (SBC)

Important SBC document information for group members

The ACA requires health insurance providers and employers to provide the SBC document to potential and current health plan members.

The final regulations require that the SBC be provided in several instances:

If written application materials are distributed for enrollment, the SBC must be provided as part of those materials. Written application materials include any forms or requests for information in paper form, website or email that must be completed for enrollment.

If written or electronic application materials for enrollment are not distributed, the SBC must be provided no later than the first date on which the participant is eligible to enroll in coverage.
If there is a change to the SBC 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.
The SBC must be provided to special enrollees no later than 90 days from their enrollment date.
If participants are required to actively elect to maintain coverage or change coverage options during an open enrollment period, the SBC must be provided at the same time open enrollment materials are distributed.
If there is no requirement to renew, and no opportunity to change coverage options, renewal is considered to be automatic and the SBC must be provided no later than 30 days before the first day of the new plan or policy year.

Prevea360 Health Plan will mail a letter to all members 30 days before their renewal date, stating how members can download their SBCs.
The SBC must be provided upon request as soon as possible but in no event later than seven business days following receipt of the request.
The SBC must be provided to the participant 60 days before the effective date of the plan change.

All mid‐contract plan change requests must be received by Prevea360 Health Plan at least 75 days before the new effective date.

About the group master policy (GMP)

The group master policy is the legal contract between your group and Prevea360 Health Plan. The policy – along with the group member certificate, the SBC, the employer application for group coverage form, the employee applications and any applicable riders, amendments and/or addendums – constitutes the entire policy between Prevea360 Health Plan and the employer group.

The first section of the policy contains a signature page that should be signed and returned after a new or revised GMP is sent to you. The coverage condition overview section contains provisions specific to your group. This is followed by the general provisions that apply to all groups.