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1001 - PHSA Section 2715: Development and Utilization of Uniform Explanation of Coverage Documents and Standardized Definitions

 
Implementation Status 
Statutory Text 

Summary

Amended by section 10101 of the Manager’s Amendment. By March 23, 2011, requires HHS to develop standards for use by plans offering group or individual health insurance coverage in compiling and providing to applicants and enrollees a summary of benefits and coverage explanation.

Requires HHS to consult with the NAIC and a multi-stakeholder working group as well as adhere to standards such as using terminology understandable by the average plan enrollee and providing a description of the coverage – including cost sharing for each of the essential health benefits categories – for illustrative common benefits scenarios.

Requires issuers to provide the summary at specified times within 2 years of enactment. Applies to health insurance issuers, including group health plans, as well as plan sponsors or administrators of self-insured plans.

#Cost-Sharing, #Transparency

Implementation Status

 
Summary 
Statutory Text 

Health insurers and group health plans began providing the Summary of Benefits and Coverage (SBC) and Uniform Glossary on September 23, 2012.

The CCIIO website has a page dedicated to these provisions where more detailed implementation information is available, including on regulations and guidance; fact sheets; and the SBC template.

Additionally, implementation information is inventoried on the DOL website, which also lists FAQs prepared jointly with HHS and Treasury on this provision from November 17, 2011, March 19, 2012, May 11, 2012 and August 7, 2012.

2012

On September 24, 2012, HHS issued a release regarding the availability of SBCs. Also see a February 9, 2012, HHS release on the final rule regarding SBCs and uniform glossaries, which is accessible via the CCIIO regulations and guidance link above.

2013

On April 23-24, 2013, DOL, HHS and Treasury released FAQs on the SBC requirements including links to templates (PDF; Word) authorized for the second year of applicability (i.e., regarding coverage starting on or after January 1, 2014, and before January 1, 2015). Also see sample completed SBCs (PDF; Word). The Departments note that the only changes from the prior year relate to denoting whether the plan provides minimum essential coverage and meets minimum value requirements under the ACA. Additionally, the FAQ provides an extension of enforcement relief through the end of 2014 for certain requirements, delineated in previous FAQs.

2014

On May 2, the DOL issued Model COBRA notices and FAQs; the notices reflect possible Marketplace coverage options. FAQs also address approaches to including out-of-network providers’ balance-billed amounts toward out-of-pocket maximums (if plans elect), reference pricing and other topics. Additional FAQs address preventive services coverage of tobacco interventions and summary of benefits and coverage requirements.

On Aug. 21, in a blog post, HHS highlighted avenues that can assist consumers in understanding their health plans, including ACA summaries of benefits and coverage (details).

On Nov. 24, CMS released a notice seeking comments on extending a currently approved information collection under the ACA Summary of Benefits and Coverage and Uniform Glossary requirements. See #1 on p. 2. Comments are due by Jan. 23, 2015. Accompanying materials are available in a Paperwork Reduction Act packages here and here.

2015

On Dec. 19, CCIIO posted data on counties meeting the 10% threshold for specified languages in which plans provide culturally and linguistically appropriate notices under these sections.

On Dec. 22, HHS, Treasury and the DOL released jointly issued a proposed rule (fact sheet) delineating changes to the summary of benefits and coverage (SBC) and the uniform glossary applicable to group health plans and health insurance coverage in the group and individual markets pursuant to the ACA. Also see updated SBC templates and further materials here under “December 2014 Proposed Supporting Materials for Public Comment.” Comments on the proposed rule are due by March 2, 2015.

On Feb. 9, CCIIO updated data on counties meeting the 10% threshold for specified languages in which plans provide culturally and linguistically appropriate notices under these sections.

On Feb. 26, HHS, DOL and Treasury released an information collection notice extending Paperwork Reduction Act authority for summary disclosures under this section, noting it will accept comments on the extension for 30 days.

On Mar. 30, CCIIO, Treasury and Labor released an FAQ indicating that they anticipate finalizing regulatory changes and updated templates in the “near  future” but that they will apply to “coverage that would renew or begin on the first day of the first plan year (or, in the individual market, policy year) that begins on or after January 1, 2017 (including open season periods that occur in the Fall of 2016 for coverage beginning on or after January 1, 2017).”

On June 12, CCIIO, Treasury, and Labor jointly issued a final rule (fact sheet; press release) effectuating changes to the summary of benefits and coverage (SBC) and uniform glossary requirements for individual and group plans under the ACA and original February 2012 implementing regulations. As indicated in March 30, 2015, FAQs, the Departments finalize the regulations but do not yet codify the revised and updated SBC templates and associated documents.

On June 19, the National Association of Insurance Commissioners issued a Request for Proposals for an organization to assist with consumer testing of new templates that are expected to be finalized by January 2016.

2016

On Jan. 28, CCIIO posted updated culturally and linguistically appropriate services (CLAS) data, which Qualified Health Plans (QHPs) use for compliance with requirements that they provide certain notices and summaries of benefits and coverage documents in applicable languages, among other rules.

On Feb. 25, CMS solicited comments on a proposed revisions to the ACA-required Summary of Benefits and Coverage and Uniform Glossary. Comments are due by Mar. 28. Also see the DOL templates, instructions, and related materials for public comment here and CMS’ Paperwork Reduction Act package.

On Apr. 6, CMS released new templates and associated documents for the ACA Summary of Benefits and Coverage (SBC) and Uniform Glossary information that group and individual health plans, including Exchange plans, must provide to enrollees (available here).

On July 22, CCIIO posted sample Summaries of Benefits and Coverage for zero cost-sharing (see here) and limited cost-sharing (see here) QHPs that are statutorily available to American Indians and Alaska Natives.

Statutory Text

 
Implementation Status 
Summary 

‘‘SEC. 2715 [42 U.S.C. 300gg–15]. DEVELOPMENT AND UTILIZATION OF UNIFORM EXPLANATION OF COVERAGE DOCUMENTS AND STANDARDIZED DEFINITIONS. ‘‘(a) IN GENERAL.—Not later than 12 months after the date of enactment of the Patient Protection and Affordable Care Act, the Secretary shall develop standards for use by a group health plan and a health insurance issuer offering group or individual health insurance coverage, in compiling and providing to applicants, enrollees, and policyholders or certificate holders a summary of benefits and coverage explanation that accurately describes the benefits and coverage under the applicable plan or coverage. In developing such standards, the Secretary shall consult with the National Association of Insurance Commissioners (referred to in this section as the ‘NAIC’), a working group composed of representatives of health insurance-related consumer advocacy organizations, health insurance issuers, health care professionals, patient advocates including those representing individuals with limited English proficiency, and other qualified individuals. [As revised by section 10101(b)] ‘‘(b) REQUIREMENTS.—The standards for the summary of benefits and coverage developed under subsection (a) shall provide for the following: ‘‘(1) APPEARANCE.—The standards shall ensure that the summary of benefits and coverage is presented in a uniform format that does not exceed 4 pages in length and does not include print smaller than 12-point font. ‘‘(2) LANGUAGE.—The standards shall ensure that the summary is presented in a culturally and linguistically appropriate manner and utilizes terminology understandable by the average plan enrollee. ‘‘(3) CONTENTS.—The standards shall ensure that the summary of benefits and coverage includes— ‘‘(A) uniform definitions of standard insurance terms and medical terms (consistent with subsection (g)) so that consumers may compare health insurance coverage and understand the terms of coverage (or exception to such coverage); ‘‘(B) a description of the coverage, including cost sharing for— ‘‘(i) each of the categories of the essential health benefits described in subparagraphs (A) through (J) of section 1302(b)(1) of the Patient Protection and Affordable Care Act; and ‘‘(ii) other benefits, as identified by the Secretary; ‘‘(C) the exceptions, reductions, and limitations on coverage; ‘‘(D) the cost-sharing provisions, including deductible, coinsurance, and co-payment obligations; ‘‘(E) the renewability and continuation of coverage provisions; ‘‘(F) a coverage facts label that includes examples to illustrate common benefits scenarios, including pregnancy and serious or chronic medical conditions and related cost sharing, such scenarios to be based on recognized clinical practice guidelines; ‘‘(G) a statement of whether the plan or coverage— ‘‘(i) provides minimum essential coverage (as defined under section 5000A(f) of the Internal Revenue Code 1986); and ‘‘(ii) ensures that the plan or coverage share of the total allowed costs of benefits provided under the plan or coverage is not less than 60 percent of such costs; ‘‘(H) a statement that the outline is a summary of the policy or certificate and that the coverage document itself should be consulted to determine the governing contractual provisions; and ‘‘(I) a contact number for the consumer to call with additional questions and an Internet web address where a copy of the actual individual coverage policy or group certificate of coverage can be reviewed and obtained. ‘‘(c) PERIODIC REVIEW AND UPDATING.—The Secretary shall periodically review and update, as appropriate, the standards developed under this section. ‘‘(d) REQUIREMENT TO PROVIDE.— ‘‘(1) IN GENERAL.—Not later than 24 months after the date of enactment of the Patient Protection and Affordable Care Act, each entity described in paragraph (3) shall provide, prior to any enrollment restriction, a summary of benefits and coverage explanation pursuant to the standards developed by the Secretary under subsection (a) to— ‘‘(A) an applicant at the time of application; ‘‘(B) an enrollee prior to the time of enrollment or reenrollment, as applicable; and ‘‘(C) a policyholder or certificate holder at the time of issuance of the policy or delivery of the certificate. ‘‘(2) COMPLIANCE.—An entity described in paragraph (3) is deemed to be in compliance with this section if the summary of benefits and coverage described in subsection (a) is provided in paper or electronic form. ‘‘(3) ENTITIES IN GENERAL.—An entity described in this paragraph is— ‘‘(A) a health insurance issuer (including a group health plan that is not a self-insured plan) offering health insurance coverage within the United States; or ‘‘(B) in the case of a self-insured group health plan, the plan sponsor or designated administrator of the plan (as such terms are defined in section 3(16) of the Employee Retirement Income Security Act of 1974). ‘‘(4) NOTICE OF MODIFICATIONS.—If a group health plan or health insurance issuer makes any material modification in any of the terms of the plan or coverage involved (as defined for purposes of section 102 of the Employee Retirement Income Security Act of 1974) that is not reflected in the most recently provided summary of benefits and coverage, the plan or issuer shall provide notice of such modification to enrollees not later than 60 days prior to the date on which such modification will become effective.

‘‘(e) PREEMPTION.—The standards developed under subsection (a) shall preempt any related State standards that require a summary of benefits and coverage that provides less information to consumers than that required to be provided under this section, as determined by the Secretary. ‘‘(f) FAILURE TO PROVIDE.—An entity described in subsection (d)(3) that willfully fails to provide the information required under this section shall be subject to a fine of not more than $1,000 for each such failure. Such failure with respect to each enrollee shall constitute a separate offense for purposes of this subsection. ‘‘(g) DEVELOPMENT OF STANDARD DEFINITIONS.— ‘‘(1) IN GENERAL.—The Secretary shall, by regulation, provide for the development of standards for the definitions of terms used in health insurance coverage, including the insurance-related terms described in paragraph (2) and the medical terms described in paragraph (3). ‘‘(2) INSURANCE-RELATED TERMS.—The insurance-related terms described in this paragraph are premium, deductible, coinsurance, co-payment, out-of-pocket limit, preferred provider, non-preferred provider, out-of-network co-payments, UCR (usual, customary and reasonable) fees, excluded services, grievance and appeals, and such other terms as the Secretary determines are important to define so that consumers may compare health insurance coverage and understand the terms of their coverage. ‘‘(3) MEDICAL TERMS.—The medical terms described in this paragraph are hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage, durable medical equipment, home health care, skilled nursing care, rehabilitation services, hospice services, emergency medical transportation, and such other terms as the Secretary determines are important to define so that consumers may compare the medical benefits offered by health insurance and understand the extent of those medical benefits (or exceptions to those benefits).

Browse ACA Titles

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  • III-Improving the Quality and Efficiency of Health Care
  • IV-Prevention of Chronic Disease and Improving Public Health
  • V-Health Care Workforce
  • VI-Transparency and Program Integrity
  • VII-Improving Access to Innovative Medical Therapies
  • VIII-Community Living Assistance Services and Supports (CLASS ACT)
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