Last reviewed: 6 October 2026

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The Summary of Benefits and Coverage: what federal rule 45 CFR 147.200 says your health plan must give you

The short answer: federal rule 45 CFR 147.200 requires a health insurer or group health plan to give you a written Summary of Benefits and Coverage (SBC) of each benefit package, free of charge.^[1] It must use a uniform format, run no more than four double-sided pages, use print no smaller than 12-point, and include cost-sharing, exceptions and limitations, and coverage examples.^[1] HealthCare.gov describes it as an easy-to-read summary that lets you make apples-to-apples comparisons of costs and coverage between plans.^[2] This page lists what the rule requires. It does not rate any plan.

The short version

• An issuer of individual-market coverage must give you an SBC as soon as practicable after you apply, and no later than seven business days after it receives the application.^[1]
• You can also ask for one before you apply: the issuer must provide it within seven business days of your request.^[1]
• The SBC is only a summary. The rule requires it to say so and to point you to the policy or certificate for the governing contract terms.^[1]
• A health insurance issuer or a non-federal governmental health plan that willfully fails to provide required information to a covered individual can face a fine of up to $1,000 per failure, adjusted annually.^[1]

What the SBC must contain

Section 147.200(a)(2) lists these required parts:^[1]

• Uniform definitions of standard insurance and medical terms.
• A description of the coverage, including cost sharing, for each benefit category the federal government specifies.
• The exceptions, reductions and limitations of the coverage.
• The cost-sharing provisions, including deductible, coinsurance and copayment obligations.
• The renewability and continuation-of-coverage provisions.
• Coverage examples (explained below).
• A statement about whether the plan provides minimum essential coverage and whether its share of total allowed costs meets applicable requirements.
• A statement that the SBC is only a summary and that the plan document, policy, certificate or contract should be consulted for the governing provisions.
• Contact information for questions.
• For issuers, a web address where you can review and obtain the actual policy or certificate.
• For plans with provider networks, an address for a list of network providers; for plans with a drug formulary, an address for drug coverage information.
• A web address for the uniform glossary, a phone number to get a paper copy, and a statement that paper copies are available.

Where a plan sold through a Marketplace excludes or covers certain services, the rule also requires a notice of that coverage or exclusion.^[1]

Format and length

• Uniform format, using terminology understandable by the average plan enrollee (or, in individual-market coverage, the average individual covered).^[1]
• No more than four double-sided pages, and no print smaller than 12-point font.^[1]
• An issuer of individual coverage must provide the SBC as a stand-alone document.^[1]
• It must be provided in a culturally and linguistically appropriate manner under the standards the rule references.^[1]

Coverage examples

The SBC must include coverage examples, specified by the federal government, that illustrate benefits for common scenarios, including pregnancy and serious or chronic medical conditions. The rule allows up to six. Each is a hypothetical sample treatment plan based on recognized clinical practice guidelines. The plan or issuer simulates claims processing to estimate what an individual might expect to pay, taking into account cost sharing, excluded benefits and other limits.^[1] An example is an illustration, not a prediction of your own bill.

When you must get one: individual-market coverage

Group health plans and issuers have parallel timing rules for plan sponsors and for participants and beneficiaries. For example, for participants the SBC must be part of written enrollment application materials, or if there are none, by the first date the participant is eligible to enroll; special enrollees must get it within 90 days of enrollment.^[1]

The uniform glossary

Separately, an issuer of individual coverage must make a uniform glossary available to applicants, policyholders and covered dependents within seven business days of a request, on paper or electronically as requested.^[1] The rule lists terms the glossary must define, including allowed amount, appeal, balance billing, coinsurance, copayment, deductible, excluded services, grievance, medically necessary, network, out-of-pocket limit, preauthorization, premium and usual customary and reasonable.^[1]

What to look for when you read one

• Cost-sharing lines: the SBC must show the deductible, coinsurance and copayment obligations, so each should be there.^[1]
• Exceptions, reductions and limitations: the rule requires them to appear. If you cannot find them, ask for the policy itself.^[1]
• Where to read the contract: for issuers, the SBC must give a web address where you can review and obtain the actual policy or certificate.^[1]
• Your network and drug information: for plans with networks or formularies, the SBC must give an address or contact for each.^[1]

Who the rule covers, and where it ends

• The rule says state laws that conflict with it, including a state law requiring an SBC that supplies less information, are preempted.^[1]
• It does not apply to a group health plan benefit package that provides Medicare Advantage benefits.^[1]

How to verify this yourself

Open section 147.200 on the eCFR and compare each required part against the SBC you were given, then read the HealthCare.gov glossary entry. If a required item is missing, ask the issuer in writing to provide a compliant SBC and keep the date of your request, because the seven-business-day clock runs from it.

What this page does not cover

We do not rate or compare any plan, and we do not say which cost-sharing structure is better. We do not cover the Department of Labor, IRS or state rules that sit alongside this rule, or the form and instructions the federal government publishes for the SBC. The rule text can be amended; the eCFR shows the current version. This is general information, not insurance or legal advice. For your own situation, ask your agent or insurer, or contact your state insurance regulator.

Your next step

Ask for the SBC of any plan you are considering before you apply, and put the issuer's seven-business-day deadline on your calendar. Our guide to deductible, copay, coinsurance and out-of-pocket maximum explains the terms you will see on it.

Related checks

Our standard explains how we check an agent's license and disciplinary history. Check an agent reports our findings at category level, as a method and not a verdict. Neither reviews any insurer, plan or product. If a plan denies a claim, see internal appeals and external review. For network types, see HMO, PPO, EPO and POS. More plain-language guides are in the agent guides.

When we will update this page

We re-read the sources when they change. If something here is out of date, tell us. Corrections are dated on the page.

References

1. [1] Electronic Code of Federal Regulations, 45 CFR § 147.200 (summary of benefits and coverage and uniform glossary), read 6 October 2026 — ecfr.gov/current/title-45/section-147.200
2. [2] HealthCare.gov, "Summary of Benefits and Coverage (SBC)" (glossary), read 6 October 2026 — healthcare.gov/glossary/summary-of-benefits-and-coverage