An Employer s Guide to the

Transcription

1 An Employer s Guide to the Click on the sections below to learn more.

2 What is the SBC The Summary of Benefits and Coverage (SBC) establishes standards that group health plan sponsors and insurers must use when offering group or individual health insurance. It was created by the departments of Health and Human Services, Labor and the Treasury. The departments consulted with the National Association of Insurance Commissioners (NAIC) to develop standards for providing SBCs. Make sure you comply! Willful failure to deliver your SBC to members within the required timeframe may result in a fine of $1,000 per each covered individual! Why the SBC requirement was created Among other things, the standards were created to ensure that benefits and coverage information is presented in clear language and in a consistent format to help consumers better understand their coverage and more easily compare coverage options. The SBC was developed under section 2715 of the Public Health Service Act (PHS Act) as added by the Patient Protection and Affordable Care Act (Affordable Care Act). This communication is for your education only. Blue Cross and Blue Shield of Louisiana is not engaged in rendering tax, legal or investment advice. We recommend that you should seek the guidance of a legal or tax professional or a financial advisor. Federal and state laws and regulations are subject to change. Insurance coverage provided by or through Blue Cross and Blue Shield of Louisiana or its affiliates. Administrative services for self-insured groups provided by Blue Cross and Blue Shield of Louisiana or its affiliates. Any reference to the information or websites of any non-blue Cross-affiliated entity is provided for informational purposes and is not an endorsement. Blue Cross and Blue Shield of Louisiana does not control the content or accuracy of these websites.

3 Click here to see the Department of Health and Human Services (HHS) sample SBC. The following information must be included on the SBC: Description(s) of the coverage Exceptions, reductions or limitations on coverage Cost-sharing provisions, including deductible, coinsurance and copayment obligations Renewability and continuation of coverage provisions Appeals/grievance rights Coverage examples with estimated customer costs based on each plan s benefits for two medical scenarios: 1) Having a Baby 2) Managing Type 2 Diabetes A statement that the SBC is only a summary and that the insurance policy or benefit plan should be used to determine the governing contractual provisions of the coverage Web address (or other contact) where a copy of the actual insurance policy or benefit plan can be reviewed and obtained Web address (or other contact) for the following: Network Providers Drug Coverage Uniform Glossary Uniform Format The SBC is not a guideline or example. It must be replicated using the exact wording, format and layout. Insurers and employers will need to insert plan details into the predetermined rows and columns. Samples and instructions may be viewed at the Department of Labor s Employee Benefits Security Administration website, Foreign language requirements for SBCs If a certain percentage of the population in a parish or county speaks a language other than English, the availability of materials in the non-english language must be communicated by: Including a notice of the availability of language assistance Providing translation upon request in certain limited languages (currently Spanish, Traditional Chinese, Tagalog and Navajo)

4 -, 2012, 2012 The effective date for providing an SBC is on and after, Enrollment during open enrollment period The requirements to provide an SBC, notice of material modification and Uniform Glossary apply for disclosures to participants and beneficiaries who enroll or re-enroll in group health coverage through an open enrollment period beginning on the first day of the first open enrollment period that begins on or after, Enrollment other than open enrollment For SBC distributions to participants and beneficiaries who enroll in group health plan coverage other than through an open enrollment period (example, special enrollees, new hires), the requirements apply beginning the first day of the first plan year that begins on or after, Upon Request Beginning, an SBC must be provided upon request to participants and beneficiaries as soon as practical, but no later than seven (7) business days following the receipt of the request. SBC distributions For SBC distributions to group health plans by an insurer, these requirements are applicable beginning, 2012.

5 For insured health plans, Blue Cross and the employer group are jointly responsible for meeting the SBC requirements for creation and delivery of the SBCs to members. Blue Cross will: Create your entire SBC for the benefits you provide your employees through Blue Cross, including one of our subsidiaries, Put it in the uniform format outlined by the Affordable Care Act and its implementing regulations, Calculate and include the coverage examples in your SBC; Deliver the SBC to you via mail or ; Distribute the SBC to your employees via mail; Update the entire SBC, going forward, whenever you request a benefit change. Note: In the pre-enrollment situation, we must rely upon you, our employer customers, or producers acting on your behalf, to deliver the SBCs to special enrollees and/or new hires. A special enrollee is generally an employee who enrolls midyear upon the occurrence of a qualifying event such as marriage, birth of a child or loss of other coverage. Stand-alone dental or vision and retiree-only plans are excluded from the SBC requirements. Group health plan SBC Member/Employee SBC Blue Cross will provide an SBC to a member: 90 days prior to the group's renewal date; Within 90 days of enrollment for special enrollees; Within seven (7) business days after a policy is issued; After, 2012, within seven (7) business days after receipt of request. The Employer must provide an SBC to a member: As part of the written application or enrollment materials (i.e., new hire enrollment packet). The SBC must be distributed no later than the first date on which the employee is eligible to enroll for coverage; For renewal, if the member must actively elect to maintain coverage, or has the opportunity to change coverage options during an annual open enrollment period, an SBC must be distributed as part of the open enrollment materials; Within seven (7) business days after receipt of request by the employee. You can make changes to your SBC at three main times. Click NEXT for more information Because Blue Cross and our subsidiary, HMO Louisiana, Inc. offer group health coverage, we will provide an SBC to the employer or group leader: 90 days prior to the group's renewal date; After a benefit change is finalized; After, 2012, within seven (7) business days after receipt of request.

6 You can make changes to your SBC at three main times. Please note the examples provided do not illustrate timeframes requiring additional information needed for plans with external vendors. If you are using an external vendor to provide some of your benefits, please include additional time to provide a consolidated and synergized SBC. 1. At renewal The timelines associated with changes at renewal are dependent upon whether the SBC update involves open enrollment or any actual benefit changes: Benefit change with open enrollment Blue Cross will provide the completed SBC electronically to you in advance of the date open enrollment materials are distributed as long as we receive notification of benefit changes at least seven (7) business days before we are required to deliver the SBC to you. Benefit change with no open enrollment Blue Cross will provide the completed SBC electronically to you prior to the effective date of the plan as long as we receive notification of benefit changes at least seven (7) business days before we are required to deliver the SBC to you. No benefit change If there are no changes to your current SBC, we will update the existing SBC to reflect the new coverage period and provide it to you electronically within the timeframes stated listed here. September 7 days October November December January September 14 Benefit changes due to BCBSLA from you. September 25 SBC due to you from BCBSLA. October 1 SBCs sent out to members for open enrollment. January 1 Benefits effective date.

7 2. Before renewal If you have changes prior to renewal, but after distribution of the first SBC, Blue Cross will provide you the completed SBC electronically by the first day of coverage as long as we receive notification of benefit change at least 30 days before the first day of coverage. Blue Cross will issue new SBCs to members within 7 business days of effective date. Example: October November December 30 days January October 1 SBCs are sent out to groups and members. November 29 You notify BCBSLA of benefit change. December 10 SBC due to you prior to the effective date. January 1 Benefits effective date. 3. Off renewal - Benefit changes Blue Cross will provide you the completed SBC electronically in advance of the effective date of the change as long as we receive notification of benefit changes 75 business days in advance from you as an existing customer. The employer or Blue Cross must provide revised SBCs to members 60 days in advance of the change. Example: January 75 days 60 days February March April May June January 1 Original benefits effective date. March 15 Benefit changes due to BCBSLA from you. Distribute SBCs to you before April 1. April 1 SBC sent to members. June 1 Effective date of change.

8 Blue Cross will: Blue Cross will work with our self-insured groups to meet the necessary SBC requirements. You, or your designated administrator, are responsible for meeting the SBC requirements for your self-insured group. Upon request (at no additional cost), Blue Cross will: Create the SBC for services we administer, Put it in the uniform format outlined by the Affordable Care Act and its implementing regulations, Calculate and include the coverage examples in your SBC, Deliver the SBC to you via your elected distribution method, and Update the entire SBC, going forward, whenever you request a benefit change. If you use external vendors to provide certain benefits, there could be additional tasks or SBCs that are required. We offer two ways to help you: 1) Full SBC Creation (Including External Vendors)** If Blue Cross provides your health claims administration, but you use external vendors for other benefits services, we will create the SBC, including calculating coverage examples, for the services that are administered by Blue Cross. Upon request, we can incorporate the completed external vendor benefit information and calculated coverage examples, into a single, completed SBC.** You will be responsible for delivering SBCs to your members; however, we can assist with member distribution, upon request.* Blue Cross can only make requested benefit change updates to the SBC going forward for the services that we provide you, unless the external vendor benefit information and re-calculated coverage examples are provided by you. Stand-alone dental or vision and retiree-only plans are excluded from the SBC requirements. * Additional fees may apply for this service. Please see your Sales Account Executive for more information on fees and other SBC services available. ** Blue Cross and its subsidiaries take no responsibility for the contents of this SBC External Vendor Form, make no representation as to its accuracy or completeness and expressly disclaim any liability whatsoever for any loss howsoever arising from or in reliance upon the whole or any part of the contents of this SBC External Vendor form.

9 Creating and distributing SBCs As a self-funded plan sponsor, you are responsible for creating and distributing the SBC. As your health claims administrator, Blue Cross will be prepared to create, calculate and deliver a full or partial SBC for those services we administer upon request.* The following is a detailed breakdown of who gets your SBC and when. We have also included details on how you may provide it to your plan members along with information on: How you can initially access your SBC once Blue Cross has completed our portion If you have services provided by other vendors, how to submit your vendor-completed SBC template to incorporate it into your SBC** * Additional fees may apply for this service. Fees may apply. Please see your Sales Account Executive for more information on applicable fees for certain SBC services available. ** Blue Cross and its subsidiaries take no responsibility for the contents of this SBC External Vendor Form, make no representation as to its accuracy or completeness and expressly disclaim any liability whatsoever for any loss howsoever arising from or in reliance upon the whole or any part of the contents of this SBC External Vendor form. Who gets your SBC You must provide your SBC to both eligible employees and their dependents. For new enrollees, you must provide an SBC for each plan the employee is eligible to enroll. For employees currently enrolled in a plan, you must provide only the SBC for the plan in which they have enrolled. You can send a single SBC to an employee and his or her dependents, if they are all living at the same address. However, if any beneficiaries live elsewhere, you need to be sure they also receive an SBC. When do they get it You must provide an SBC in the situations listed here. Upon enrollment At renewal Off-renewal changes Upon request Special enrollees

10 Upon enrollment The group must provide the SBC as part of any written application materials that the group distributes for enrollment. If the group does not distribute written application materials for enrollment, the group must distribute SBCs no later than the first date on which the employee is eligible to enroll in coverage for the employee or any beneficiaries. At renewal How and when you should provide SBCs at renewal depends on several factors: 1) When a reapplication is required If written applications are required for renewal (paper or online), you must provide the SBC no later than the date on which the materials are distributed. 2) Automatic renewal The SBC Final Rule states that, in general, if a renewal or reissuance of coverage does not require reapplication, the SBC must be provided no later than 30 calendar days prior to the first day of the new plan year. If employees are eligible to change coverage elections during an annual open enrollment period, you must provide the SBC with the open enrollment materials. 3) SBC change If any plan changes reflected in the SBC are made after the initial SBC is distributed, but before the first day of coverage, an updated SBC must be provided no later than the first day of coverage. Off-renewal changes Advance notice of material modification is required for a change that occurs other than in connection with a renewal. You must notify your employees at least 60 calendar days before the effective date of the change, if the change affects information included in the SBC and is not reflected in the most recent SBC. Upon request If a request is received, the SBC should be provided as soon as possible, but never later than seven (7) business days. When you have special enrollees A special enrollee is a plan member who has a HIPAA Special Enrollment event, such as a marriage or birth of a child or loss of other coverage. You must provide the SBC no later than 90 calendar days from enrollment, which is when a summary plan description is required under the timeframe set forth in ERISA. What is a material modification? A material modification is any change to the coverage offered under a plan that independently or in conjunction with other modifications or changes that is considered an important change in covered benefits or other terms of coverage under the plan or policy. Important changes include: Elimination of benefits Reduction of benefits under the plan, including formulas, methodologies or schedules that serve as the basis for making benefit determinations Increases in benefits under the plan Increases in deductibles, coinsurance, copayments or other amounts to be paid by a participant or beneficiary Decreases in deductibles, coinsurance, copayments or other amounts to be paid by a participant or beneficiary Changes in state mandates for non-erisa plans that are contained within the SBC Establishment of new conditions or requirements (for example, prior authorization requirements) for obtaining benefits under the plan

11 How you may provide your SBC Your SBC may be provided in paper form, by or by posting it online. Electronic transmission requirements Your SBC can be provided electronically to members who are eligible for, but not enrolled in, coverage if the following conditions are met: 1) The format is readily accessible 2) A paper copy is provided free of charge upon request, and 3) If it is posted online, an or paper form notification, including the Web address, must be sent to the employee stating the SBC is available online and available in paper form upon request. Accessing your SBC Once Blue Cross has finished creating your SBC, we will share a copy with you in your preferred communication method of paper copy or .

12 Here are several links to government websites where you may find more information about the SBC regulations and requirements: Federal Regulations Compliance Instruction Guide Electronic Delivery Uniform Glossary Contact us If you have questions about your Blue Cross SBC, please contact your Regional Office or your agent. Alexandria Coliseum Blvd., Suite A Alexandria, Louisiana Baton Rouge Reitz Ave. Baton Rouge, Louisiana Houma St. Charles St., Suite 135 Houma, LA Lafayette Johnston St., Suite 200 Lafayette, Louisiana Lake Charles West Prien Lake Rd. Lake Charles, Louisiana Monroe Mercedes Dr. Monroe, LA New Orleans North Causeway Blvd., Suite 600 Metairie, Louisiana Shreveport Ashley Ridge Blvd. Shreveport, Louisiana 71106