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.

President Obama's PPACA to Receive Supreme Court Ruling

The long awaited review of the Patient Protection and Affordable Care Act (PPACA) by the Supreme Court is in sight. On Monday, it was announced that the Supreme Court would rule on the bill during the 2011-2012 term. The Individual Mandate, requiring citizens to purchase healthcare or face a fine, is the controversial core of the legislation’s legal battle:

The president, a Democrat, has championed the individual mandate as a major accomplishment of his presidency and as a way to try to slow soaring health care costs while expanding coverage to the more than 30 million Americans without it.

The 11th Circuit Court of Appeals, based in Atlanta, ruled 2-1 last month in favor of 26 states and others that challenged the mandate for exceeding the power of Congress.

The current administration is convinced of the Individual Mandate’s constitutionality. According to Reuters, the administration had the option of asking the Court of Appeals to reconsider their position prior to the Supreme Court level, but the risk would have pushed back any Supreme Court ruling to the 2013 term.

The PPACA is potentially the most significant accomplishment of the Obama Administration, leading many political analysts to believe that the Supreme Court’s ruling will be among the deciding factors in the upcoming 2012 election. If the administration is as confident as they claim, it should come as no surprise that they wanted to push the ruling out before the major business of election campaigns begins.

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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.

News From The 2011 CMS Fall Conference

The CMS Fall Conference this year can be defined with one word: improvements. The conference was designed with a series of breakout sessions, each intended to give CMS experts the ability to hear questions, concerns, and criticisms from those of us in the industry. It wasn’t a one-way conversation, however, as the experts in attendance provided plenty of information and commentary.

As I have already said, CMS made a great effort to stress their initiatives for improving Medicare and Medicaid programs. These efforts will include:

• Valuable products
• Clear benefits
• Accurate communications
• Accurate benefits
• No tricks at educational events
• Regulation-consistent marketing
• Secret shopping
• A stricter policy on misleading print ads and marketing

On a more positive note, CMS experts were enthusiastic about Part C and Part D programs. They were quick to stress that existing programs were not bad, but that they could do more. These initiatives are all intended to lead to better care, healthier communities, and conformity to ACA law.

The other major point of discussion was the CMS star rating system. A perfect five-star rating can bring many advantages to a plan, including year-round marketing to beneficiaries turning 65. A beneficiary may join or switch to a five-star plan from an MA, MAPD, or PDP plan, barring a few limitations:

• Beneficiaries can only join a plan in their area.
• They can only enroll in a 2012 plan with a five star rating.
• A beneficiary can only use this process one time per year.
• If one moves from a plan with drug coverage to a five-star plan that does not have drug coverage, they lose that coverage and cannot return to their previous plan.

CMS warned plans that deliberately structuring themselves to maximize ratings would not be an effective tactic, and that if plans stay focused on overall quality of care, and appropriate care, their star rating will be good.

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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.