Summary of Benefits and Coverage (SBC) Provision

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One of the new requirements under the Patient Protection and Affordable Health Care Act (known as PPACA or Health Care Reform) is that group health plan participants must receive a Summary of Benefits and Coverage (SBC). The SBC contains a summary of the key benefits and cost-sharing provided through the health plan, a link to the glossary of terms, and a discussion of some other policy conditions or limitations. Per regulation, issuers are required to provide an SBC for actively sold products on or after September 23, 2012.

Actively-marketed products are those that are part of CareFirst’s marketed portfolio of standard products currently being sold, i.e., not currently subject to the benefit streamlining project.

The Department of Health and Human Services (HHS) has instructed that SBCs for products that are not actively marketed must be available on for before September 23, 2014. CareFirst anticipates that the SBCs for its full portfolio of products will be available by September 23, 2014.

FAQs on the SBC have been issued by HHS. (Question 12, of the HHS issued FAQs, is a particularly relevant for brokers.)

  • Part VII
    This set of FAQs addresses the Summary of Benefits and Coverage and Uniform Glossary requirements of PHS Act §2715 and the Mental Health Parity and Addiction Equity Act of 2008.
  • Part VIII
    This set of FAQs addresses the Summary of Benefits and Coverage requirements of PHS Act §2715.
  • Part IX
    This set of FAQs addresses the Summary of Benefits and Coverage requirements of PHS Act §2715.
  • Part X
    This FAQ addresses the Summary of Benefits and Coverage requirements of PHS Act §2715.
  • Part XIV
    This FAQ addresses the second year of Safe Harbor and the Second Year of Applicability of the Summary of Benefits and Coverage requirements of PHS Act §2715.

Purpose

The idea behind the SBC is to offer improved, uniform information to consumers in clear language so they can easily understand the health coverage they have, as well as enable them to compare their current coverage to other types of plans and insurance products.


Components

The SBC regulation provides member access to two key documents:

  1. The SBC, which provides members with a standardized format which describes benefits and coverage simply and consistently so that members can compare plan benefits among and between insurance carriers. An example of an SBC can be found on the U.S. Department of Labor website.
  2. The SBC Glossary, which contains definitions of commonly-used health coverage and medical terms.

Key Points to Keep in Mind

  • For Risk Accounts: CareFirst will provide a URL link to the SBCs in PDF form with renewal materials and/or contracts to the employer group for distribution. The SBCs will contain integrated medical and Rx information if Rx is provided through CareFirst. Otherwise, the account needs to contact its Rx vendor to provide this information. Remember however, that SBCs will only be available if the employer’s plan is still actively marketed by CareFirst.
  • For Self-Insured Accounts: CareFirst will provide SBCs in Word format with renewal materials and/or contracts for the accounts to update, as necessary. There will be no charge for this service to self-insured accounts. Self-insured accounts are responsible for the accuracy of the SBC and are responsible for distributing the SBCs to their employees and other beneficiaries.
    • NOTE: The SBC format was determined by HHS, and HHS regulations specify the contents of the SBC. CareFirst cannot change or alter that content beyond what is permitted by regulation. CareFirst is restricted to the government-approved language and format. CareFirst is continuing to provide other plan summary materials, in addition to the SBC.
  • Any renewal quotes for products that CareFirst actively sells will contain a URL to the SBC. Technically, CareFirst is not required to provide an SBC for alternative quotes. We are required to provide SBCs for renewals and for the product the group selects or has selected. Therefore, we will not be generating SBCs for alternative quotes at this time. SBCs need to be generated only for accounts that are marked SOLD in Broker Express.
  • All contracts will contain the appropriate SBC in the form of a URL link to the SBC in PDF form.

Part of CareFirst’s implementation process for creating and accessing SBCs has been delayed due to the considerable administrative demands of this project.

Until further notice, this is the interim process for requesting an SBC on or after September 23, 2012:

Brokers:

  • Broker receives a request for an SBC by email or phone.
  • Broker submits SBC request to the SBC Project email address: SBCProject@carefirst.com
    • The request should include the Broker’s name, request date, group or individual name, product ID (PDPDID Identifier), product name and Rx product ID (PDPDID identifier).
    • The SBC request will be fulfilled and forwarded to the Broker Requestor to send to the account.

For Consumer Direct, and Small and Medium and Large groups who have standard benefits:

  • Online access to SBCs for an Individual member's health plan is available on My Account.
  • Large Group Members can access SBCs by contacting their Group Benefits Administrator.
  • Small and Medium Group members should contact their Group Administrator for a copy of their SBC. Reminder: SBCs are only available if the group has a product that is still being actively marketed.
    • Group Administrators can access the URL link if it has been previously provided by CareFirst with their renewal or contract or request the URL link by contacting their broker representative or sales service representative. In order to open and save the PDF, Group Administrators will need Adobe Acrobat or Adobe Reader on their computers. It is recommended Internet Explorer should be used to view the documents.
  • Individual members will receive a URL link at their Policy anniversary or if new to CareFirst the URL link will be in their policy documents. New Individual members can also contact Member Services for the URL link to the SBC.
    • Member Service representatives can send link, PDF or hard copy to Individual members. Please be aware that in order to open and save the PDF, all members will need Adobe Acrobat or Adobe Reader on their computers. It is recommended Internet Explorer should be used to view the documents.

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Reminder

SBCs will be available only for actively-marketed products. SBCs for Groups or Individual members who have a product that is no longer marketed will be available on or before October 2013.

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