Implementing Health Reform. On April 6, 2016, the Centers for Medicare and Medicaid posted the final 2017 summary of benefits and coverage (SBC) template, group and individual market SBC instructions and uniform glossary of health coverage and medical terms. They also released a final coverage example calculator and calculator instructions.
The SBC is issued jointly by CMS with the Departments of Labor and Treasury and is to be used by all health plans, including individual, small group, and large group; insured and self-insured; grandfathered, transitional, and ACA compliant. The new SBC must be used for plan years with open enrollment periods beginning after April 1, 2017, and thus will not be used for marketplace plans for the 2017 coverage year.
SBCs are intended to provide a uniform format for describing health plan benefits to allow health insurance shoppers to make apples-to-apples comparisons among available health plans, and to assist enrollees to better understand and use their own coverage. The uniform glossary of coverage and medical terms is to be used in tandem with the SBC to assist users in understanding terms used in the SBC.
The final SBC is the product of a year and a quarter-long process of revising the original SBC issued by the Departments in 2012. In December of 2014 the departments issued a notice of proposed rulemaking, proposing changes both in the SBC rule and in the template. A final rule, which primarily addressed issues involving the distribution of SBCs, was finalized in June of 2015 . In March of 2015, however, the departments stated that they would bifurcate the process and hold up on issuing the template until they received further input from the National Association of Insurance Commissioners (NAIC) and consumer testing.
The NAIC convened a stakeholder group (of which I was a member) which drafted and consumer-tested a proposed revision to the SBC. The NAIC sent its proposed SBC template to the departments in October and proposed revisions to the uniform glossary to the departments in early December.
The departments released a proposed revised SBC template, proposed individual and group instructions, and a proposed uniform glossary for comment on February 25, 2016. I described the template, instructions, and glossary in an earlier post here.
The differences between the current and the 2017 SBC were described in some detail in the earlier post. The biggest differences are the addition of a new coverage example (for a simple fracture) and new requirements for information about services covered before a deductible and about "core" limitations and exceptions. Core limitations and exceptions include categories of services that are substantially excepted from coverage, situations where cost sharing on a covered service does not count toward the out-of-pocket limit, numerical or dollar limits on services, and prior authorization requirements. The new SBC also must describe abortion coverage for qualified health plans and may for other plans.
The biggest innovation of the final SBC is that terms used in an electronic SBC can be fully hyperlinked to the uniform glossary. The current glossary is a single pdf file, but each term of the new glossary can be linked independently to the SBC. The terms used on each definition in the glossary are also hyperlinked to their definitions in the glossary. Insurers can also link to the glossary by hovering over a term.
The final SBC template is essentially unchanged from the proposed version. The only perceptible difference is that the coverage examples now accommodate both plans that use coinsurance and plans that use copayments for the services listed. The uniform glossary is also essentially unchanged except that several definitions have been edited for readability.
There are more changes between the proposed and final instructions, but these are quite technical. The instructions regarding embedded deductibles say somewhat more clearly that where a plan has both an individual and family deductible and the deductible is embedded, the plan will begin to cover the costs of an individual family member once the individual deductible has been met for that individual. Other family members must, however, meet their own deductibles before their costs will be covered until the total family deductible is met.
If a plan or insurer has a deductible and it does not apply to a particular benefit, the final instructions require the plan to note this in the "what you will pay" column. Finally, plans and insurers must note in the coverage examples where the plan has deductibles that apply to specific services.
The coverage example cost sharing calculator packet instructions describe in detail the plan parameters that must be entered into the calculator and the sequence in which they must be entered. The instructions are very technical and will not be described here.
from Health Affairs BlogHealth Affairs Blog http://ift.tt/1NarrNP
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