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Time to Regroup: A Permanent Solution
for Summary of Benefits and Coverage
April 2013
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Introduction
When provisions of the Affordable Care Act (ACA)
went into effect, many insurers scrambled to
meet the requirements for the plain language
documents mandated by the legislation. The
deadline for producing compliant Summary of
Benefits and Coverage (SBC) documents was
Sept. 23rd, 2012.
While most insurance providers met the
deadline, many did so by cobbling together bits
and pieces of information from silos of data
spread across the enterprise. This was clearly a
temporary and makeshift response that became
necessary as insurers struggled with a
compressed timeframe brought about by delays
in the development of rules and guidelines. Final
rules were published in February 2012,
prompting questions from health plans that were
still being answered in March. Faced with an
extraordinarily short development schedule,
health insurers developed solutions that may not
be suitable for long-term use. Continuing to use
temporary SBC processes into 2014 and beyond is
a risky business practice.
Solutions developed under a looming deadline
are often of the “one-off” variety. Unfortunately
for insurers, production of SBC documents is an
ongoing responsibility. Insurers are required to
furnish the documents at various lifecycle events
to new enrollees, at policy renewal time, within
sixty days of mid-year plan modifications, and
within seven days of ad hoc requests. This
requirement is further complicated by the
provision that issuing SBCs applies to all
individual policyholders, and to both fully insured
and self-insured groups. Without solid automated
procedures in place, insurers could be in danger
of committing violations at any time.
Legacy Systems Make Integration Difficult
Over half of the mid-size and large insurers in the
US are still using at least some legacy mainframe
systems for critical business functions including
policy administration, claims processing, and
billing. The consolidation of carriers over the past
20 years has resulted in some major insurance
companies using different systems to administer
their various products. These systems may not
work together seamlessly and the application
code may be written in older languages such as
COBOL. Carriers with a large number of selfinsured groups have the greatest challenge.
These groups generally have unique plan designs
and offer their employees multiple coverage
options which translates into the need for
customized SBC documents for each group.
Construction of compliant SBC documents may
require the retrieval and matching of data from
sources that have historically been housed in
separate systems. Combine this with the fact that
the majority of programmers who knew the
legacy programming languages have retired, and
the mainframe and older client-server
applications have been patched and modified
profusely over the years. So IT managers are
hesitant to make any further modifications.
Hence the temporary work-around approaches
adopted to achieve initial compliance with ACA
requirements.
A template-driven solution that empowers
business professionals, rather than taxing
valuable IT resources, to easily construct
documents with data from existing systems, is
the way for companies to comply with all
regulatory, legal, financial and marketing
standards while remaining flexible to make
changes to meet evolving rules and
interpretations.
Financial Risk Abounds
The financial risk to insurance companies whose
SBC composition systems may produce late or
inaccurate documents (or fail completely) are
substantial. Fines of $1,000 per affected
individual per day are allowed under the ACA
legislation. Given the speed at which many of
these SBC processes were created, it is likely that
little to no automated quality control or accuracy
assurance capabilities were developed.
© Xpertdoc Technologies Inc. All rights reserved.
All other trademarks are the property of their respective owners.
1160 Levis Street, Suite 102, Terrebonne (Quebec), Canada J6W 5S6
Page| 3
As a result, insurers are now faced with
expensive manual reviews or suffering the
uneasiness associated with sending out SBC
documents that could contain undetected errors.
Additionally for many carriers, front-end
interfaces suitable for business users to generate
documents may not have been developed. As a
result, precious IT resources are likely being
called upon at short-notice for the on-demand
production of SBCs.
Xpertdoc Meets the Needs of Many Health
Insurance Firms
Within 2 days of learning of the ACA mandate for
producing SBC forms, Xpertdoc produced a
sample SBC document (pictured below) that was
launched on their Cloud platform that allowed
carriers to see how rapidly they could become
compliant with the new regulatory requirements.
This initiative showcased Xpertdoc’s agility,
responsiveness, and understanding of the
mandated requirements, the data integrations
required, and the challenges this represented to
the health insurance industry.
Many Blue Cross & Blue Shield Plans across the
country learned about Xpertdoc’s SBC focus and
reached out for help in addressing their specific
needs for a solution. Within a matter of weeks on
each engagement, Xpertdoc built and installed a
complete solution that brought the various Blue
Cross & Blue Shield Plans into full compliance
with the SBC reporting requirement. With the
recently published regulations for 2014, Xpertdoc
has already made the necessary changes to the
SBC document templates. Xpertdoc’s use of
business rules to select the appropriate template
and data will allow client companies to produce
SBCs compliant with 2013 and 2014 rules
simultaneously based on specific circumstances.
Leveraging the experience Xpertdoc has had
working with many of the Blues and other
insurers, Xpertdoc is now reaching out to health
insurance companies to offer a proven and stable
solution that allows them to replace their fragile
and risky SBC document composition schemes
with a permanent solution specifically designed
to respond to an ever-changing regulatory
environment.
Xpertdoc mitigates the risk of non-compliance,
without the need for a large professional services
engagement or significant legacy system
integration support.
The Xpertdoc Solution is scalable and robust
enough to help medium and large health
insurance companies comply with the SBC
guidelines prescribed by the Affordable Care Act.
Companies can be sure that there are more ACA
compliance requirements on the horizon that will
need to be addressed. Companies with a solid
Xpertdoc composition engine in place will be well
positioned to quickly and easily remain compliant
with future regulatory changes while minimizing
complications and the need for committing
significant internal resources.
© Xpertdoc Technologies Inc. All rights reserved.
All other trademarks are the property of their respective owners.
1160 Levis Street, Suite 102, Terrebonne (Quebec), Canada J6W 5S6