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Agencies Propose Revisions to Summary of Benefits and Coverage

The Department of Health and Human Services (HHS), the Department of Labor (DOL), and the Internal Revenue Service (IRS) (the agencies) have released proposed regulations that would modify the required content of the summary of benefits and coverage (referred to as "SBC") by a group health plan or health insurance issuer. The proposed regulations would revise the existing regulations (issued in 2012) by modifying the template SBC, the uniform glossary, and clarifying some rules about issuing SBCs in certain circumstances.

Effective Dates: If finalized as written, the proposed regulations take effect for disclosures to participants who enroll or re-enroll in group health coverage through an open enrollment period beginning on the first day of the first open enrollment period that begins on or after September 1, 2015. For participants who enroll or re-enroll in group health coverage other than through an open enrollment period, the new rules are proposed to apply for plan years beginning on or after September 1, 2015. Early adoption is not addressed in this proposed regulation.

Action to Take: Plan sponsors who wish to provide comments must do so by March 2, 2015.

Changes in the Summary of Benefits and Coverage Regulations

The proposed regulations would make a number of changes in the content of the SBC, the uniform glossary, and in the regulations. Highlights of the proposed changes as they pertain to group health plans are as follows:

Changes to the Content of the SBC

  1. Revises SBC template to 5 pages from 8.
  2. Removes two questions on page 1, the definitions at the top of page 2, headers on pages 2-5, footers (except page numbers); condenses the explanation of rights to continued coverage, and provides for combined language on minimum essential coverage and minimum value into one or two paragraphs (per instructions).
  3. Adds a third example on an emergency room visit for a simple fracture.

Changes to the Uniform Glossary

  1. Adds the following 15 terms: Claim, Cost Sharing, Cost-Sharing Reductions, Diagnostic Test, Formulary, Individual Responsibility Requirement, Marketplace, Minimum Essential Coverage, Minimum Essential Coverage Exemption, Minimum Value Standard, Premium Tax Credits, Preventive Care, Referral, Screening, and Specialty Drug.
  2. Revises the definitions for the following 15 terms: Appeal, Coinsurance, Deductible, Durable Medical Equipment, Emergency Medical Condition, Emergency Medical Transportation, Emergency Room Care, Health Insurance, Home Health Care, Non-Preferred Provider, Out-of-Pocket Limit, Preferred Provider, Primary Care Provider, Provider, and Skilled Nursing Care.

Clarifications of SBC Notification Procedures

  1. If an SBC was provided to a participant prior to application for coverage, and there is no change to the information required to be provided, then the SBC does not need to be provided again upon application for coverage.
  2. If the plan sponsor is negotiating coverage terms after an application has been filed and the information required to be in the SBC changes, the plan or issuer is not required to provide an updated SBC until the first day of coverage (unless an updated SBC is requested, then they have 7 business days to do so).
  3. a participant is automatically re-enrolled, only the SBC provided for the benefit package in which the participant or beneficiary will automatically be re-enrolled needs to be provided unless a request is made for a different benefit package.
  4. If a group health plan uses two or more insurance products provided by separate issuers to insure benefits under the plan, then the group health plan administrator is responsible for providing complete SBCs with respect to the plan.
  5. If a group health plan contracts with another party to provide an SBC, the group health plan would be considered to satisfy the requirements if it: i) monitors performance and ii) corrects noncompliance once known (assuming the plan has the information to do so) or (if the plan does not have the information to do so) communicates to participants the noncompliance and the steps being taken to remedy the situation.

A sample completed SBC with the proposed revisions may be found at the DOL website at http://www.dol.gov/ebsa/pdf/sbccompletedsampleproposed.pdf.

The proposed revised glossary may be found at http://www.dol.gov/ebsa/pdf/sbcuniformglossaryproposed.pdf.

The proposed regulations can be found at http://webapps.dol.gov/FederalRegister/HtmlDisplay.aspx?DocId=28023&AgencyId=8&DocumentType=1.

How to Submit Comments

Comments identified by "Summary of Benefits and Coverage" can be submitted by one of the following:

  • Federal eRulemaking Portal: http://www.regulations.gov. Follow the instructions for submitting comments.
  • Mail or Hand Delivery: Office of Health Plan Standards and Compliance Assistance, Employee Benefits Security Administration, Room N-5653, U.S. Department of Labor, 200 Constitution Avenue NW, Washington, DC 20210, Attention: Summary of Benefits and Coverage.

Cheiron consultants can assist with the analysis of the proposed changes to the SBC for your plan.

Cheiron is an actuarial consulting firm that provides actuarial and consulting advice. However, we are neither attorneys nor accountants. Therefore, we do not provide legal services or tax advice.

 
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