Friday, November 11, 2011

A Summary of Uniform Coverage (Part 2)

Back in October, we began a series of blogs describing the proposed regulations issued by the Departments of Health and Human Services, Labor and Treasury on August 17, 2011. A few time-sensitive industry events have occurred in between, but we are now happy to be back on track.

When we last left off, we had described some of the basic requirements of ‘The Summary of Benefits and Coverage,’ or SBC. In this blog, we will go into some more detail on 12 of those requirements with help from a general list provided by HHS.

  • Uniform definitions of standard insurance terms and medical terms so that consumers may compare health coverage and understand the terms of (or exceptions to) their coverage.
  • A description of the coverage, including cost sharing, for each category of benefits identified by the HHS Secretary in guidance.
  • The exceptions, reductions, and limitations of the coverage.
  • The cost-sharing provisions of the coverage, including deductible, coinsurance, and copayment obligations.
  • The renewability and continuation of coverage provisions.
  • Coverage examples in accordance with the regulation as identified by the HHS Secretary.
  • A statement that the SBC is only a summary and that the plan document, policy, or certificate of insurance should be consulted to determine the governing contractual provisions of the coverage.
  • Contact information for questions and obtaining a copy of the plan document or the insurance policy, certificate, or contract of insurance (such as a telephone number for customer service and an Internet address for obtaining a copy of the plan document or the insurance policy, certificate, or contract of insurance).
  • For plans and issuers that maintain one or more networks of providers, an Internet address (or similar contact information) for obtaining a list of network providers.
  • For plans and issuers that use a formulary in providing prescription drug coverage, an Internet address (or similar contact information) for obtaining information on prescription drug coverage.
  • An Internet address for obtaining the uniform glossary.
  • Premiums (or in the case of a self-insured group health plan, cost of coverage).
In our next blog, we will provide some more detail, information, and analysis of the SBC proposals.


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

1 comment:

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