Summary of Benefits and Coverage Fact Sheet For Agents and Group Administrators September 2012 The Patient Protection and Affordable Care Act (PPACA) created a new federal requirement to provide two federal forms to covered health plan members following strict delivery and distribution guidelines. These forms are the Summary of Benefits and Coverage and the Uniform Glossary of Terms. The Summary of Benefits and Coverage (SBC) The Summary of Benefits and Coverage (SBC) is an eight-­‐page form. It contains basic information about a particular health plan’s benefit options such as cost sharing (deductible, copayments, etc.) and other coverage details and any limitations to those benefits. The date we are required to begin producing SBCs is September 23, 2012. SBCs will include “coverage examples.” These coverage examples are general cost estimates for selected types of health conditions utilizing a government-­‐developed formula. The coverage examples in the SBC are “Having a Baby (normal delivery)” and “Managing Type 2 Diabetes (routine maintenance of a well-­‐
controlled condition)”. It’s important to note that since these examples will use a standardized formula for calculating costs, the examples will vary from the actual amounts any insurance plan would cover for these conditions. It should not be used as a cost estimator. The SBC must be mailed or delivered electronically within 7 days of a request or upon certain timeline “triggers” described later in this document. The Uniform Glossary of Terms The Uniform Glossary of Terms provides definitions of common health insurance terms using definitions provided by the United States Department of Health and Human Services. Some of these definitions differ from the definitions used by Arkansas Blue Cross and Blue Shield and its family of companies. The definitions, as defined in the plan’s benefit certificate or evidence of coverage supersede the definitions provided in the Glossary of Terms. This Glossary is available online. It is also available as a printed copy upon request. Printed copies must be mailed to the requestor within 7 business days. It may be requested by calling the Customer Service phone number for the appropriate company. These numbers are found at the end of this document. 1 MPI# 1243 8/12 The SBC, Glossary of Terms and Arkansas Blue Cross The terms of the 2010 Health Care Reform legislation dictates the form, manner and delivery timeline of these federal documents. The remainder of this document outlines the procedures that Arkansas Blue Cross and its family of companies will use to comply with this legislation. Will Arkansas Blue Cross and its family of companies be compliant with the law by September 23, 2012? Yes. Does the SBC replace any existing documents? No. Arkansas Blue Cross and its family of companies will continue to provide benefit summaries, benefit certificates, personal health statements and other coverage information publications as they do currently. In many cases, these traditional documents will provide information that is more complete and accurate than the SBC or Glossary of Terms. It all cases, the formal Benefit Certificate or Evidence of Coverage are the final authority of coverage that a health plan provides. Who Will Create and Distribute the SBC? Arkansas Blue Cross or the appropriate affiliate company (e.g. HealthAdvantage) will produce the Summary of Benefits and Coverage reflecting the benefits for each plan. These copies will be provided online. Printed copies are available on request. How will the SBC be distributed? For individuals (members who are not part of an employer’s group coverage), Arkansas Blue Cross will provide information to the member on how to locate the SBC online at arkbluecross.com\sbc. Directions on how to find an SBC online will be delivered to individual members through e-­‐mails or traditional mail during the application process. For yearly renewals, individual members will be notified that a new SBC for the next policy year is available to view through a notice in Blue & You, our quarterly member magazine. Directions on how to access the SBC will be provided in that annual notice. For members who have employer-­‐sponsored group health coverage, we will provide the online location of the SBC to group administrators via the employer group application. It will be the responsibility of each group to provide the SBC to covered members according to the federally-­‐mandated schedule. This schedule is described in a subsequent portion of this document. BlueAdvantage Administrators of Arkansas It is the responsibility of the self-­‐funded group to create copies of the SBC (electronic or print) and distribute it to covered members in a manner consistent with federal guidelines. Groups receiving a Summary Plan Description (SPD) from BlueAdvantage will receive an SBC, this is included as part of the BlueAdvantage services for preparation of the groups SPD at no additional charge. Self-­‐Funded groups 2 MPI# 1243 8/12 that prepare their SPD without BlueAdvantage assistance are solely responsible for the preparation of the SBC and subsequent distribution. SBC benefits not administered by Arkansas Blue Cross If certain health benefits are not provided by Arkansas Blue Cross (drug coverage, for example), the SBC that we will create will not reflect coverage details provided by other companies. In those cases, it will be the responsibility of the employer to create additional SBCs that offer coverage information from other providers. It is permissible for the employers to distribute multiple SBCs that reflect benefits provided by more than one company. What types of health insurance plans are covered by this requirement? All types of health insurance plans intended for people under age 65 marketplace are required to provide covered members with an SBC. More specifically, this includes open and closed blocs of business, grandfathered and non-­‐grandfathered plans. What types of health insurance plans are NOT covered by this requirement? Medicare or Medicare Advantage plans are not required to have an SBC. Life, dental and vision insurance plans will not have an SBC. Is there premium information on an SBC? No. Receiving Notice of An SBC Individuals How will individuals (non-­‐group members) receive notice of an SBC? At application When applications (including change forms when requesting benefit changes) are entered into our system, an e-­‐mail or letter will be sent to the applicant (prospect) letting him know where and how he can access the SBC online. Applicants who have e-­‐mail addresses always will receive this information via that channel. Current members can go to this portal and enter their member number to access their SBC. The web address for this portal is arkbluecross.com/sbc. 3 MPI# 1243 8/12 Client requests a benefit change during the application process If, for example, a prospect receives a surcharge and – before signing and returning the amendment – asks to have his deductible raised to lower his premium, a new SBC will be generated to reflect that change. A new e-­‐mail or letter will be sent to the prospect letting him know where and how he can access his SBC online. Renewals Individual members will be notified that an SBC is available for the new year in the autumn issue of Blue and You, our quarterly member magazine. This issue is in members’ homes on or about October 1. A link to the individual member’s SBC will be located in the “Benefits” section of My Blueprint beginning November 15 of each year. Until the new year begins (January 1), the member will see SBCs reflecting both the current and new year’s benefits. After January 1, only the SBC for the current year will be displayed. 4 MPI# 1243 8/12 Material Modification If Arkansas Blue Cross changes the policy during the year, a new SBC is generated. The individual member will be notified about the SBC by e-­‐mail or letter. It will be available on My Blueprint. Shopping The federal government uses the term “shopping” to describe all of the sales activities that occur prior to the application. We are not required to provide an SBC during this process. We believe a better, more accurate product comparison is available on our corporate Web site arkansasbluecross.com. Groups How will group employers (and group members) receive notice of an SBC? Shopping We will provide an SBC “upon the request” from the employer group. We can provide an SBC only for contracts in the final proposal stage. New Business Information on where the group plan administrator can find the SBC will be on the group application under the signature line. This will serve as the group’s notification. It will be the responsibility of the 5 MPI# 1243 8/12 employer / group administrator to distribute the SBC to covered employees according to the specifications of the ruling. Renewals Typically an SBC will be available for the group’s current benefit plan. If the group changes benefits during the sales process, a new SBC will be created when the signed, employer application is submitted. The online location for the new SBC will be indicated on the renewal application that the group signs. This will serve as the group’s notification. SBCs will be available online throughout the year using the link provided on the employer application at arkbluecross.com/esbc and healthadvantage-­‐
hmo.com/esbc or on Blueprint for Employers (only certain groups have access to this site.) Material Modification If we (any of the Arkansas Blue Cross family of companies) make a change the policy during the year that would affect the current SBC, a new SBC is generated. The employer group will be notified about the SBC by e-­‐mail 60 days prior to the new effective date. It is the responsibility of the group’s plan administrator to distribute the SBC to the group members. 6 MPI# 1243 8/12 What are the distribution guidelines for employer group plan administrators? Unlike other aspects of PPACA that are effective with the plan year of a group policy, the implementation of the SBC requirement is more complex for the first year. The SBC requirement undergoes a “rolling implementation” that begins after the initial date of September 23, 2012. This process recognizes the fact that group enrollment and effective dates are scattered throughout the year and may precede the implementation date. In addition to this text, there is a helpful chart at the end of this document. Beginning September 23, Arkansas Blue Cross will create SBCs for groups with signed applications that have an effective date of October 1, 2012, or after. In most cases, for the first groups provided with an SBC, the open enrollment date for the group will have passed. The group will be responsible for distributing the SBC to covered group members in print or digital format. For groups with corporate Web sites, it is permissible to post the SBC on the Web (see qualifications for Web distribution below). For future dates, when distribution of an SBC before open enrollment is possible, group employers are required to provide access to an SBC with any written materials that are distributed prior to open enrollment. If written materials are not provided prior to open enrollment, an SBC must be provided (digital or print formats) by the first day of the open enrollment period. This is the “enrollment period,” not “effective date.” Special enrollees (those enrollees who enroll after the open enrollment period), must be provided with an SBC appropriate for the group plan within 90 days. Electronic delivery specifications An SBC can be provided electronically to members who are eligible for, but not enrolled in, coverage if the following conditions are met: o
o
o
The format is readily accessible A paper copy is provided free of charge upon request, and If an Internet posting is used, an e-­‐mail or paper form notification must be sent to the employee stating the SBC is available on the Internet. This notification should include the Web address and tell the member that a paper version of the SBC is available on request. For groups with multiple plans, a group plan administrator must make the appropriate SBC available for every benefit package in which the participant or beneficiary is eligible to enroll. Can a covered member of an employer group find a copy of his or her SBC on our Web site? A digital copy (PDF) of an SBC is available in the member’s My Blueprint or My Tracker portal. The SBC has its own button in the left navigation bar in the Benefits section. Individual (non-­‐group) members may see two SBCs in My Blueprint beginning November 15th of each year. The two SBCs would be for the current year and the next year’s coverage. After January 1, only the current year will be available. 7 MPI# 1243 8/12 Group members who have not signed up for My Blueprint will be referred to their employer group plan administrator to get the appropriate SBC. Agents How will independent agent / brokers be able to review an SBC provided to their client? Agents will be able to download a PDF copy of the SBC that was provided to their client from the Blueprint for Agents Web portal. 8 MPI# 1243 8/12 How should an agent respond to a request from a group plan administrator for an SBC? A group can request an SBC at any time during the year. The agent can fulfill that request directly or it can refer the request in writing to his Arkansas Blue Cross Agent / Broker representative. If the Agent would like us to fulfill the request for an SBC, the request must be sent to an Agent / Broker representative in writing to satisfy our tracking requirements. This request can be sent as an e-­‐mail. Are their fines for non-­‐compliance with the SBC requirement? There are no fines for the first year. In the second year, there are significant fines for “willful” non-­‐
compliance with the SBC requirement. These fines can be as high as $1,000 per occurrence. The HHS holds the insurance company, the agent and the group accountable for these fines. Can a group request changes to the text or design used in a SBC? The text and design has been created by Health and Human Services, it may not be changed. Could the template or information presented in an SBC change at a later date? Yes. We anticipate changes to the current document in 2014. What are the requirements for employer group administrators to provide an SBC to beneficiaries of covered employees? 9 MPI# 1243 8/12 If the group plan administrator knows that a beneficiary of a covered employee lives at a different address than the covered employee, the plan administrator must make an SBC available to that beneficiary at that address. If the group plan administrator does not know that the covered beneficiary lives at a different address, there is no requirement to provide an SBC to that beneficiary. However, if a beneficiary notifies the group plan administrator that he or she would like to receive an SBC, no matter what his or her address, the group plan administrator must provide an SBC within seven work days to that beneficiary. Another aspect of the legislation dictates that an SBC must be provided to a potential beneficiary of a covered member. In other words, if a covered member is engaged, the future groom or bride may request an SBC from the plan administrator. Any beneficiary of an employer group health plan may request a printed copy of the SBC. How does the SBC requirement affect employees who are receiving COBRA benefits? If a former employee is receiving COBRA benefits during the open enrollment period, that enrollee must receive an SBC prior to the first date of open enrollment. If can be provided electronically (via e-­‐mail) or as a printed copy. The former employee may request the SBC to be mailed to him or her in a printed version. Can a group with carve-­‐out benefits provide separate or partial SBCs to members? Yes. Regulations from HHS that were released on May 11, 2012, allow a group to issue multiple SBCs, that combined, provide all the information to complete an SBC. The employer group should also issue guidance to a covered group member on how to utilize this information to understand their coverage. Employer group administrators may also combine information from multiple benefit providers on a single SBC. Delivery Timeline Chart Delivery Timelines Groups Event SBC Requirement How Received Group has open No. There is no N/A enrollment prior to requirement to provide September 23, 2012 an SBC prior to September 23, 2012, for open enrollment. Group has an effective No. We will not issue N/A date prior to September SBCs for effective dates 23, 2012 prior to September, 23 2012 SBC year provided N/A N/A 10 MPI# 1243 8/12 Group is enrolled and has an effective date of October 1 or after Yes. Employer groups must provide an SBC electronically or as a printed version. Group has an open enrollment after September 23, 2012 Yes, if the first date of open enrollment is on September 23 or after. If open enrollment has begun prior to September 23, there is no requirement to provide an SBC during open enrollment. Yes 2013 Ongoing On September 23, Yes Individual (non-­‐group members will have an SBC available on My Blueprint or My Tracker. Annual renewal: 2013 Yes SBCs will be available on November 15, 2012 on My Blueprint Upon application, after September 23, 2012. Yes On or before 2012 or 2013, as September 23, 2012, appropriate SBCs will be provided to group administrators via an e-­‐mail which will identify the location of the appropriate SBCs on our Website. On or before 2013 September 23, 2012, Groups will receive SBC location information on their signed contracts. Groups will receive SBC 2013 and the following location information for years their plan on the signed application. Individual (Non-­‐group members) SBCs will be available 2012 on My Blueprint or My Tracker in the benefits section. Existing members will be notified that a new SBC is available for review in a notice in the October issue of Blue & You. Applicants will receive information about the Web location of an SBC via an e-­‐mail or letter. This notice might include information on two SBCs that cover the current year and the next, if the application occurs in the fourth quarter of any year. 2013 and the following years 2012 and following years as appropriate 11 MPI# 1243 8/12 Further information Are foreign language versions available? If a member would like to discuss the contents of an SBC in an alternate language, they should call the main Customer Service number for the appropriate insurance company (a list of customer service phone numbers appears at the end of this document). We will use three-­‐way calling with an interpreter to explain the SBC in the appropriate language. What is the definition of the delivery requirement of 7 work days? If mailed, the mandated delivery requirement is that the SBC must be placed in U.S. Mail within 7 business days from the date of the request. It is not meant to indicate the “in home” date. If sent electronically, a PDF of the SBC must be sent within seven business days from the date of the request. What if the plan information does not fit within the federal template? The ruling instructs health plans to follow the template as closely as possible. Health plans have been given permission, however, to make minor modifications to the template in cases where it is necessary. In these rare cases, the Summary of Benefits and Coverage may be longer than 8 pages. What if the state already has standards for the appearance of benefit summaries? For the purposes of the SBC, federal guidelines will override any state rules and regulations regarding benefit summaries. State guidelines will be applied to any other documents that we may create. Who can I contact for more information? Agents may contact their Arkansas Blue Cross and Blue Shield Agent/Broker representative. Group administrators may contact their Group Service Representative or Agent / Broker rep. 12 MPI# 1243 8/12