Summary of Benefits and Coverage and Uniform Glossary: Templates, Instructions, and Related Materials – for use on or after 04/01/17 (Final)
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).
The agencies have released the final revised template and related materials for the summary of benefits and coverage (SBC), making good on last month’s promise to “expeditiously” finalize these items (see our Checkpoint article). The final versions, which will replace materials in use since 2012, largely reflect the most recent proposals (see our Checkpoint article). (Updated SBC materials were first proposed in December 2014; see our Checkpoint article.) Here are some highlights of the changes:
SBC Template and Instructions. The template itself is substantially similar to the most recent proposal. In the “Why This Matters” column relating to the “Important Questions” chart, the prescribed language for describing certain coverage components—including services covered before the deductible is met, embedded deductibles for family coverage, and out-of-pocket limits—has been made clearer and more straightforward. For the coverage examples, the instructions explain that the generic “[cost sharing]” notations in the template should be replaced with the appropriate cost-sharing category (e.g., copayment, coinsurance) to accurately reflect the plan. Overall, the instructions provide more details than the currently applicable instructions—for example, specifying where in the SBC the plan should add premium information, if it voluntarily chooses to do so.
Uniform Glossary. A few glossary definitions have been somewhat revised, but no new terms have been added to those in the proposed versions. For plans using an electronic SBC, the agencies have provided the capability (via a list of “anchors”) to hyperlink defined terms directly to the definition on the dedicated Uniform Glossary website.
Also included are updated coverage example calculators and information for simulating coverage examples. Use of the new SBC template and related materials is required starting with the first day of the first open enrollment period that begins on or after April 1, 2017 with respect to coverage for plan years beginning on or after that date. (So, for calendar-year plans, the new materials will be used for the 2017 open enrollment period relating to coverage beginning on or after January 1, 2018.) For plans that do not use an annual open enrollment period, these materials must be used beginning on the first day of the first plan year that begins on or after April 1, 2017.
EBIA Comment: At the time the agencies issued final SBC regulations in 2015 (see our Checkpoint article), they did not address whether the good faith compliance standard (most recently extended “until further guidance” by the agencies’ May 2014 FAQ guidance; see our Checkpoint article) continues to apply. Now that revisions to the SBC template and related materials have been finalized, it remains unclear whether the good faith compliance standard still applies—confirmation would be welcome. 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)”), EBIA’s Group Health Plan Mandates manual at Section XXVIII.C (“SBC Disclosures About Group Health Plan Mandates”), and EBIA’s Consumer-Driven Health Care manual at Section XXV.D.4.f (“Application of SBC Requirement to HRAs”). You may also be interested in our upcoming webinar “It’s Almost Open Enrollment: Do You Know Where Your SBC Is?” (live on June 16).
Contributing Editors: EBIA Staff.