Final Regulations on Summary of Benefits and Coverage Released

On February 9, 2012 the Departments of Labor, Treasury and Health & Human Services released the final regulations under Affordable Care Act (ACA) that require health insurers and group health plans to provide information about health plan benefits and coverage to those with private health coverage.

According to regulators these rules will ensure consumers have access to two key documents that will help them understand and evaluate their health insurance choices:

• A short, easy-to-understand Summary of Benefits and Coverage (SBC);
• A uniform glossary of terms commonly used in health insurance coverage.

All health plans will provide an SBC to prospective enrollees and enrollees at significant points in the enrollment process, such as upon application or at renewal. A key feature of the SBC is a new, standardized plan comparison tool called “coverage examples.” The coverage examples will illustrate sample medical situations and describe how much coverage the plan would provide.

These Rules apply to both fully-insured and self-insured plans. It is anticipated that for fully insured plans the carriers will be creating the documents and possible distributing. Self-insured plans will need to begin discussions with their plan administrators (ASO vendor, TPA, etc) to determine who will be responsible for document creation and distribution.

Effective date:

First plan year on or after September 23, 2012

Differences between proposed and final rules:

• Premium amounts are no longer mandatory on the SBC.
• If eligible for coverage but not yet enrolled, plans may send a paper postcard electronically or through regular mail to provide instructions for accessing the SBC online.
• “Best efforts” allowed for describing terms that do not lend themselves well to plain language; e.g., tiering for prescriptions and providers. 
• Coverage examples illustrative of how plans would cover treatment and services were reduced from three medical scenarios to two (Having a baby and Managing type 2 diabetes).
• SBCs for group health plans may now be included with other documents (e.g., summary plan description) as long as it is “prominently displayed” at the beginning of the document.

Links

• FAQs Regarding Summary of Benefits and Coverage (SBC)
• Summary of Benefits and Coverage Template
• Instructions for Completing the SBC
• Uniform Glossary of Coverage and Medical Terms