A Summary of Uniform Coverage (Part 1)

On Tuesday, March 23rd, 2010, President Obama signed into law the “Patient Protection and Affordable Care Act” (“PPACA”). A Reconciliation Bill making changes to the Act was signed by the President on March 30th, 2010.  On August 17, 2011, the Departments of Health and Human Services, Labor and Treasury issued proposed regulations for implementation of the Summary of Benefits and Coverage and the Uniform Glossary requirements under Section 2715 of the PPACA. Per regulation the Uniform Coverage Summary is now called “The Summary of Benefits and Coverage” or the “SBC”.

The proposed regulations provide rules for providing participants and beneficiaries with an accurate Summary of Benefits and Coverage (SBC). The proposed regulations also provide rules for SBCs that must be provided by insurers to plan sponsors wishing to purchase group health insurance. The rules apply to both group health plans and health insurers providing insurance in the group and individual markets. The rules also apply to Employee Retirement Income Security Act (ERISA) and non-ERISA group health plans and include grandfathered plans.

Here is an overview of the SBC requirements:

Every health insurer in the individual and group markets, and every group health plan (insured or self funded) must provide policy holders or certificate holders (“Subscribers/Members/Beneficiaries”), applicants, and enrollees a SBC using a uniform format that accurately describes the benefits and coverage under the plan. This was called the Uniform Coverage Summary (UCS) and is now known via regulation as the Summary of Benefits and Coverage (SBC). Under the new proposed regulations health plans are provided instructions, templates, samples, a guide for coverage example calculations to be used in completing the SBC template which includes a “Why this Matters” column and a Uniform Glossary of terms and definitions to help with beneficiary understanding.

Health plans are required to send each member an SBC and Coverage Examples. The Uniform Glossary of terms and definitions must be made available upon request in paper or electronic form within 7 days of request. The Uniform Glossary is provided by HHS and issuers cannot make any modifications to this glossary. Translation services for the SBC will follow the 10% by county rule.

Next week, we will go into further detail on what this will mean to both the business community and the American public.

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Pam Argeris is a thought leader in the Healthcare Industry and possesses extensive, hands-on experience with CMS compliance, and multiple regulatory bodies such as NCQA, JACHO, and DOI. In her role at Merrill Corp., Pam focuses on developing solutions for compliance and quality assurance, delivered in a cost effective manner to improve beneficiary and prospect communications. You can contact Pam at Pamela.Argeris@merrillcorp.com.