The Employee Benefits Security Administration (EBSA) is trying to get employers and their benefits advisors ready to issue summaries of benefits and coverage (SBCs) by the Sept. 23 compliance date.
The Patient Protection and Affordable Care Act of 2010 (PPACA) will require health insurers and employers to provide standardized, 4-page SBCs. The SBCs are supposed to help individuals and employers make apples-to-apples comparisons when they’re shopping for coverage.
The SBC would include a summary of basic plan features, along with coverage examples that show how a specific enrollee’s plan would work if the enrollee had a baby, were managing Type II diabetes, or were dealing with other common illnesses, chronic conditions or life events. Consumers would get SBCs when they apply for coverage or enroll in group plans. Consumers also could get SBCs upon request.
PPACA opponents are still trying to block PPACA with lawsuits, bills in Congress and regulatory maneuvers.
Federal agencies have postponed compliance dates for other initiatives in the past and could do so for the SBC requirements.
Some critics have argued that the SBC requirements will be hard on small issuers and small plans, because the requirement that issuers and plans provide individualized SBCs means that many SBC providers will have to have systems capable of generating a huge number of SBCs in a relatively short period.
Some issuers may have delayed implementation in the hope that the U.S. Supreme Court would reject PPACA. The court held in June that Congress did have the authority under the Constitution to include a provision that imposes a tax on individuals who fail to own a minimum level of health coverage starting in 2014.
If current rules prevail, the SBC requirements will take effect Sept. 23 for individual coverage and for group plan open enrollment periods that begin on or after Sept. 23.
EBSA has updated the PPACA section on its website by adding an SBC template in the Microsoft Word format, a sample of a completed SBC, and the latest individual policy issuer and group health plan SBC instructions.
In the instructions, officials state, for example, that managers of a plan that offers a wellness program must complete the calculations for releated treatment scenarios based on the assumption that the patient will enroll in the relevant wellness program.
With the projection of pregnancy-related costs, the plan must include a note stating that, “These numbers assume the patient has given notice of her pregnancy to the plan. If you are pregnant and have not given notice of your pregnancy, your costs may be higher.”
Similarly, the SBC issuer must warn a recipient with diabetes that the recipient’s costs might be higher than shown in the SBC if the recipient is not participating in the issuer’s diabetes wellness program.