Final Rule on
Summary Benefits and Coverage
Requirements
Who: Affects anyone issuing or covered under group and individual health policies whether fully insured or self-insured, including grandfathered plans.
When: On June 16, 2015, HHS, the DOL, and the Treasury jointly published the Final Rule governing “Summary Benefits and Coverage” (SBC). The effective dates are: September 1, 2015 for group health plans and January 1, 2016 for individual health plans.
What: The Patient Protection and Affordable Care Act requires health plans to provide a document called a “Summary Benefits and Coverage” (SBC). It is intended to help consumers compare and select health coverages that best meet their needs using easy-to-understand language of health plan benefits.
Executive Summary: The SBC is an additional mandated document to educate consumers it does not replace the more detailed traditional Summary Plan Description (SPD).
The SBC must include 12 basic elements, as detailed in previous government rulings:
The Final Rule gives additional clarifications and requires:
1. An OnLine internet website address where coverage details can be reviewed.
2. Plans to monitor the compliance of any third party contracted to provide the SBC.
3. Insurers to disclose what type abortion services are covered or excluded.
4. A separate SBC for each product, with an option to provide a combined SBC if the plan uses two or more products from separate insurers within a single health plan.
The Final Rule DID NOT finalize an official SBC form. Such form is proposed to be finalized by January 1, 2016 and required for use during the open enrollment for the first policy anniversary on or after January 1, 2017. Until a final form is detailed, no enforcement action is likely for those making good faith efforts to communicate the requirements of the SBC in written and electronic forms.
Actions: Group health plans and insurers should carefully review the new requirements and make changes to assure compliance by the effective dates. They may need to consult with their H.R. specialists, IT staff, lawyers, and other consultants to meet a short time frame for implementation. Additional changes may be required when the final SBC form is released for use in 2017.
The information presented and contained within this article was submitted by Ronald E. Bachman, President & CEO of Healthcare Visions and Chairman of the IHC Editorial Advisory Board. This information is general information only, and does not, and is not intended to constitute legal advice. You should consult legal advisors to determine the laws and regulations applicable to your company. Any opinions expressed within this document are solely the opinion of the individual author.