What is Required in the Summary of Benefits and Coverage? Part II

September 13, 2011 (PLANSPONSOR.com) - The Departments of Health and Human Services, Labor, and Treasury published a proposed rule under PPACA that requires group health plans to provide participants and beneficiaries with a uniform Summary of Benefits and Coverage. 


We discussed these new rules in last week’s column and continue with more frequently asked questions.  

What Coverage Examples Must Be Provided in the SBC?

The agencies issued a template showing what information must be included in the SBC.  This includes coverage examples for common benefits scenarios adopted by HHS.  The coverage examples would be based on criteria provided by HHS that all plans must use (such as type of treatment and dates of service).  The plan then would have to calculate and report whether the service would be covered and what level of cost-sharing would apply.  Initially, HHS has adopted three coverage examples – for pregnancy, breast cancer treatment, and diabetes.  The proposed rule states that HHS may adopt up to six coverage examples.

HHS will specify the information necessary to create the coverage examples on its website (http://cciio.cms.gov) and update this information annually.  Plans must incorporate any new information from the HHS website into their coverage examples in the next SBC required 90 days after the website is updated.   

What Are The Formatting Requirements for the SBC?

The proposed rules require that the SBC be a stand-alone document, although the Preamble solicits comments on whether a plan should be permitted to provide the SBC in the SPD or other plan materials.  The SBC may be no more than 4 pages (front and back – a total of 8 pages) in 12-point font.  The Preamble notes that the SBC may be printed in color or black and white. 

Must the SBC Be Translated into Non-English Languages?

The proposed rule requires that the SBC be provided in a “culturally and linguistically appropriate manner.”  The rule says that a plan will be considered to meet this requirement if thresholds and standards under the PPACA appeals rules are met.  The appeals rule requires plans to disclose the availability of language services and translate adverse benefit determinations into a non-English language for notices sent to addresses in certain counties that have been identified by the US Census Bureau as having a concentration of non-English speakers.  A recent amendment to the appeals interim final rule includes a chart of such counties and the applicable languages (which are Spanish, Mandarin, Navajo, and Tagalog).  76 Fed. Reg. 37208 (June 24, 2011).


May the SBC Be Delivered Electronically?

For ERISA group health plans, the SBC may be delivered in electronic form if the delivery meets ERISA’s general delivery rules at 29 CFR § 2520.104b-1 (which include the electronic delivery safe harbor).  For non-federal governmental plans, the SBC may be delivered in electronic form if the delivery meets either ERISA’s general delivery rule or special rules related to electronic delivery for individual coverage.

What is the Uniform Glossary and How Must it Be Delivered?

The proposed rules require that group health plans also make a glossary available to participants and beneficiaries with uniform definitions for all plans (plans may not modify the uniform glossary).  The SBC must disclose the right of an individual to request a copy of the uniform glossary, and plans must make the glossary available upon request in either paper or electronic form (as requested) within 7 days.

When Must Plans Start Providing SBCs?

PPACA required that HHS deliver SBC standards by March 23, 2011 and that plans begin delivering SBCs by March 23, 2012.  Even though HHS missed its deadline to issue regulations (and then issued proposed regulations that are subject to change), the proposed rule does not extend the applicability date.  However, the Departments did seek comments on the feasibility of the effective date.


Got a health-care reform question?  You can ask YOUR health-care reform legislation question online at http://www.surveymonkey.com/s/second_opinions  

You can find a handy list of Key Provisions of the Patient Protection and Affordable Care Act and their effective dates at http://www.groom.com/HCR-Chart.html   


Christy Tinnes is a Principal in the Health & Welfare Group of Groom Law Group in Washington, D.C.  She is involved in all aspects of health and welfare plans, including ERISA, HIPAA portability, HIPAA privacy, COBRA, and Medicare.  She represents employers designing health plans as well as insurers designing new products.  Most recently, she has been extensively involved in the insurance market reform and employer mandate provisions of the health-care reform legislation.

Brigen Winters is a Principal at Groom Law Group, Chartered, where he co-chairs the firm's Policy and Legislation group. He counsels plan sponsors, insurers, and other financial institutions regarding health and welfare, executive compensation, and tax-qualified arrangements, and advises clients on legislative and regulatory matters, with a particular focus on the recently enacted health-reform legislation.

PLEASE NOTE:  This feature is intended to provide general information only, does not constitute legal advice, and cannot be used or substituted for legal or tax advice.