Summary of Benefits and Coverage - Anthem Health Care Reform ...

Health Care Reform
Summary of Benefits and Coverage
On Thursday, February 9, 2012, the Health and Human Services Department, Department of Labor and Department
of Treasury concurrently released the Final Rules on the Summary of Benefits and Coverage (S BC) provision with
accompanying instructions for completing the forms and a September 23, 2012 , implementation date.
The interim SBC rules were released last August, and extensive comments were submitted to the agencies by trade
associations, business groups, consumer advocates and health insurers. Since filing comments, we and other
industry representatives have been advocating our positions with the agencies through various channels.
Based on our initial review of the Final Rules, the agencies made onl y several minor changes and have a short
compliance timeframe.
Provision Overview
Many of the specific requirements did not change with the most recent regulations. Below is a quick summary of
what is required.
Insurers must provide a standardized benefit summary and coverage to explain medical plans, specifically:
Fully insured and ASO plans. We are reviewing the final regulations to determine how we can support our
self-funded clients.
All Group sizes – Small Group, Large Group and National Accounts
All Individual consumers
Both Grandfathered and Non-Grandfathered plans
4 –page (front /back) document comprised of:
The Coverage Summary (a.k.a. Benefits Summary)
A Common Glossary of terms (defined by HHS)
Coverage Facts Labels (samples illustrating common benefit scenarios)
Highly prescriptive format
Does not allow for customization depending on type of medical plan
12 Point Font
Specific instructions on data placement
Compliance
Fine of up to $1000 per consumer per instance for non -compliance
$100 / day until we are compliant
States may also fine

Distribution
Mail, fax and email are viable distribution channels subject to various detailed requirements
1. Group Business (Small Group, Large Group, National Accounts)
o Requests for medical information/application
o Pre-enrollment for participants to compare during the selection process
o Issuance of policy/certificate
o Renewal/Material Modification
2. Individual (Under 65)
o Shopping/Time of Application
o Issuance of policy/certificate
o Upon Request
o Renewal/Material Modification
Material Modification and 60-day Advance Notice applies to changes during a policy period – it does not
apply to changes made at renewal.
Final Rule Outcomes
A review of the final regulation indicates that the agencies made only several min or changes. Below is a recap of
the requirements in the final rule:
Item
Final Rule
Compliance Date Individual coverage issued on or after September
23, 2012
Group coverage for open enrollments beginning on
or after September 23, 2012
Culturally and
Linguistically
Appropriate
Renewals
The agencies will provide translations of the SBC template,
sample language, and the Uniform Glossary in the languag es
of Spanish, Tagalog, Chinese and Navajo.
The agencies provided flexibility in that if the policy has not
been issued or renewed prior to 30 days before the renewal
date, the SBC must be provided as soon as practicable but
no later than 7 business days after issuance of the new policy
or receipt of written confirmation of intent to renew,
whichever is earlier.

Insertion of premium
figures in the SBC
Glossary of Health
Coverage and
Medical Terms
The agencies omitted the requirement for carriers to insert
premium figures in the SBC.
New Disclaimer added to indicate the terms used are not the
same as their plan’s, and in the event of a conflict the plan
language would govern
Exclusion of the large
group market
The agencies have not excluded the large group
market from the SBC requirements.
Distribution rules for the group market indicate that
the SBC can be combined with other materials
(such as the Summary Plan Description) if the SBC
is in the front of the document and contains all the
required information
Individual market, the SBC must be a stand-alone
document
Coverage Examples
Notice of Material
Modification
The agencies rejected both positions
Reduced the required coverage examples from 3 to
2, omitting the breast cancer example and retaining
the maternity and Type 2 diabetes examples
The agencies commented that for 2014 they will be
adding more examples
No substantive changes to this requirement
Template Forms Insurers must use the template SBC forms
developed by the NAIC
The templates are for use in the first year - on or
after 9/23/12
Agencies anticipate changing the templates for
2014
If plans do not neatly fit within the template, the
instructions provide that insurers must use their
best efforts to describe the plan consistent with the
template format

Electronic Delivery
Distribution of SBC to
beneficiaries living at
a different address
The rules for electronic delivery in the individual market were
relaxed somewhat.
Summary for all Lines of Business:
E-delivery to group itself - no change
E-delivery to group (both self-funded and fully
insured) pre-enrollees – new rules similar to the
electronic delivery requirements for providing the
SBC to a group health plan.
E-delivery to group enrollees – no change – must
comply with ERISA safe harbor requirements for
distribution of electronic documents
E-delivery to individual consumer market –
liberalized distribution rules
The agencies made no changes to this requirement
Seven (7) day
distribution period
The 7-day period was expanded slightly to be seven
business days.
We are working diligently to finalize our approach to SBC implementation and how we will support our
clients based on the final rules. We will continue to update you.
This content is provided solely for informational purposes. It is not intended as and does not constitute legal advice. The information contained herein should not
be relied upon or used as a substitute for consultation with legal, accounting, tax and/or other professional advisers.
Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route
123. Anthem Blue Cross and Blue Shield and its affiliated HMO HealthKeepers, Inc. are independent licensees of the Blue Cross Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance
Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
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