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PPACA: Feds to Avoid Imposing SBC Penalties

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Even the government has a hard time getting its Summaries of Benefits and Coverage (SBC) perfect.

Officials from the U.S. Department of Labor, the U.S. Department of Health and Human Services and the U.S. Treasury Department admit as much in a new batch of answers to frequently asked questions about implementation of the Patient Protection and Affordable Care Act of 2010 (PPACA).

Most of the answers are responses to questions about SBCs and a related document, a “uniform glossary” of health benefits terms.

Congress included the SBC and glossary requirements in PPACA in an effort to help consumers understand their health coverage better and do a better job of shopping for coverage.

An SBC is supposed to include a summary of basic plan features, along with coverage examples, or “scenarios,” that show how a plan would work if an enrollee had a baby, were managing Type II diabetes, or were dealing with other common illnesses, chronic conditions or life events.

Consumers will get SBCs when they apply for coverage or enroll in group plans. Consumers also can get SBCs upon request.

The SBC requirements are set to take effect Sept. 23 for individual coverage and for group plan open enrollment periods that begin on or after Sept. 23.

Officials note that one of the questions often asked deals with just how aggressive regulators will be about throwing the book at health insurers, employers, plan administrators and others that fail to meet SBC and glossary requirements.

The departments have said before that their basic approach to PPACA implementation will be to try to work employers, issuers and other stakeholders to help them comply with PPACA, and the departments say they are sticking with that philosophy.

“During this first year of applicability, the departments will not impose penalties on plans and issuers that are working diligently and in good faith to comply,” officials say.

Officials add that they will give issuers until Sept. 23, 2013, to provide SBCs for products that are no longer actively marketed. The federal agencies also plan to wait an extra year to take any enforcement actions against issuers of expatriate plans that have not yet sent out SBCs, officials say.

The officials report that they themselves had a problem with creating their own SBC-related document — a hypothetical diabetes treatment scenario.

“In the diabetes treatment scenario, the version originally posted contained a typographical error, listing the allowed amount for insulin as $11.92, rather than $119.20,” officials say.

The error affects examples of the approach filers should use when calculating the total cost of care for diabetes, officials say.

To correct the error in the hypothetical diabetes treatment scenario, the departments have posted updated versions of the SBC template, the sample completed SBC, and the diabetes scenario in the guide for coverage examples calculations.

In responses to other questions, officials say:

  • A health insurance issuer must provide an SBC when a consumer applies for coverage “as soon as practicable, but no later than 7 business days after receiving a substantially complete application for a health insurance product.”
  • A consumer who has received an SBC before applying for coverage need not get a duplicate SBC upon applying for coverage, as long as the SBC has not changed.
  • A consumer who received an SBC when before applying for coverage or when applying for coverage need not get a duplicate SBC when the coverage takes effect, unless the consumer asks for another SBC or the SBC has changed.
  • An issuer may have to provide an SBC for a group health plan or sponsor that’s shopping for coverage if the group plan asks for specific information about the coverage, but an issuer need not send out an SBC in response to general questions about coverage options or general discussions about health products.


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