Second Opinions
Summary Judgments
What is required in
the summary of benefits
and coverage?
On August 22, 2011, the Departments
of Health and Human Services, Labor,
and Treasury published a proposed rule
under PPACA that requires group health
plans to provide participants and beneficiaries with a uniform Summary of Benefits and Coverage (SBC) ( 76 Fed. Reg.
52442). The proposed rule also requires
plans to provide a uniform glossary to
participants upon request. Comments
were due October 21, 2011. The requirement is effective March 23, 2012.
Below, we will answer questions that
health plans have been asking about
these new rules.
Who Must Provide the sBC?
The new summary of benefits requirement applies to insured and self-funded
ERISA group health plans, including
grandfathered plans, as well as to non-ERISA group health plans. The new rules
also apply to individual health insurance coverage. The departments request
comment as to whether the requirement
should apply to expatriate health insurance coverage.
What Information Must Be Included
in the sBC?
The agencies issued a template showing
what information must be included in
the SBC and in what format. The SBC is
limited to four pages (front and back—
eight pages total) in 12-point font. The
SBC template requires reporting of:
• Uniform definitions;
• The plan’s cost-sharing provisions,
including deductibles, co-insurance,
and co-payments;
• Renewability and continuation of
coverage provisions;
• For coverage beginning on or after
1/1/14, a statement whether the plan
provides minimum essential coverage
and whether the plan’s share of total
allowed costs of benefits meets applicable requirements;
• A statement that the SBC is a summary
only and that the plan document or
policy should be consulted to deter-
mine governing provisions;
• Contact information for questions or
to obtain a copy of the plan or policy;
• If the plan maintains more than
one network, the Internet address
or similar contact information for
obtaining a list of network providers;
• If the plan uses a prescription drug
formulary, the Internet address or
similar contact information for
obtaining information on prescription
drug coverage;
• The Internet address for obtaining the
uniform glossary;
• Information on premiums for insured
coverage or the cost of coverage for
104 PLANSPONSOR.com November 2011 Illustration by Katherine Streeter
