Information Collection Request: Summary of Benefits and Coverage and Uniform Glossary Required Under the Affordable Care Act, 81 Fed. Reg. 9887 (Feb. 26, 2016); Templates, Instructions, and Related Materials—Proposed (NEW)
Visit the Health Care Reform Community on Checkpoint to join the discussion on this development (for Checkpoint subscribers to EBIA’s Health Care Reform manual).
Proposed revisions to the template for the summary of benefits and coverage (SBC) and related materials have been issued by the agencies, along with a request for comments from interested parties. The revised materials propose further changes to the versions initially proposed in December 2014 (see our Checkpoint article). The new proposed template (like the earlier proposal) comprises 2-1/2 double-sided pages of prescribed content, making it shorter than the template currently in use. Here are some highlights:
- “Important Questions” Revised. As with the earlier proposal, the new proposed template would eliminate, from the “Important Questions” section, the question about annual limits (as they are no longer permitted) and the question about what is not covered (the SBC would still address noncovered services elsewhere). The new proposed template also presents questions about deductibles, out-of-pocket limits, and network providers differently—for example, asking “Will you pay less if you use a network provider?” rather than “Does this plan use a network of providers?”
- Disclosures Modified. Revised disclosures about continuation coverage and grievance and appeals rights would be required to appear as shown on the template, with additional language (specified in the instructions) required based on factors such as whether the plan is subject to ERISA. The new proposed template also includes disclosures indicating whether the plan provides minimum essential coverage (MEC) and meets the minimum value (MV) standards. Along with a yes or no answer, specific language addressing potential tax consequences (individual shared responsibility), exemptions, and the premium tax credit would be required. Until the template and related materials are finalized and applicable, information regarding MEC and MV may be provided in a separate document.
- Coverage Examples Changed. The new proposed template includes the third coverage example involving a simple fracture, which also appeared in the earlier proposal. Additional proposed revisions to the coverage examples would provide clearer information about the plan’s deductibles and coinsurance, and eliminate hypothetical costs for specific services under each scenario such as hospital charges, lab tests, and prescriptions. The coverage example calculators would remain available to use in completing the examples, along with proposed narratives and guides to the calculations. As in the earlier proposal, the SBC template page that explains assumptions and other information about the coverage examples would be eliminated.
- New Instructions Added. The revised instructions for completing the SBC would include some new elements, such as information about addressing coverage or exclusion of abortion services on the SBC. Other proposed revisions to the instructions incorporate previously issued guidance on issues such as combining information for different cost-sharing options and explaining the effect of “add-ons” like a health FSA, HRA, HSA, or wellness program. (See, for example, our Checkpoint article.)
- Uniform Glossary Definitions Linked in SBC. Proposed changes to the uniform glossary itself are largely similar to those in the earlier proposal. Proposed revisions to the instructions for completing the SBC note that terms defined in the glossary should be underlined in the SBC, and, in electronic versions, may hyperlink directly to the definition.
EBIA Comment: SBC final regulations issued in June 2015 indicated that a revised template and related materials would be finalized by January 2016 (see our Checkpoint article). Perhaps the delay, and these new proposed revisions, reflect a desire for more input from stakeholders. (The comment period ends March 28, 2016.) For instance, we note that the agencies previously requested comments regarding plans that have difficulty providing the required information in the specified format, and what accommodations may be appropriate for those plans (see our Checkpoint article), but the revised materials do not appear to include much more concrete guidance for such plans. For more information, see EBIA’s Health Care Reform manual at Section XVI (“Summary of Benefits and Coverage (SBC)”) and EBIA’s ERISA Compliance manual at Section XXIV.O (“Summary of Benefits and Coverage (SBC) Under Health Care Reform”). See also EBIA’s Self-Insured Health Plans manual at Section XXVIII.C (“Summary of Benefits and Coverage (SBC)”) and EBIA’s Group Health Plan Mandates manual at Section XXVIII.C (“SBC Disclosures About Group Health Plan Mandates”).
Contributing Editors: EBIA Staff.