Earlier this month, the final rule covering the “Summary of Benefits and Coverage and Uniform Glossary” was issued by the Departments of the Treasury, Labor and Health and Human Services (“the Departments”). The final rule includes provisions originally published in the version proposed in 2011 along with changes and additions based on feedback received during the comment period.

The provisions of the final rule apply to group and individual health plans under the Patient Protection and Affordable Care Act (PPACA) adopted in March 2010, and apply beginning September 23 of this year, delayed by six months after receiving input from affected organizations and evaluating the implementation needs involved.

In addition to requirements for a uniform glossary of terms, the rule addresses issues such as notice of material modifications affecting summaries of benefits and coverage (SBCs)and appearance of and language in SBCs, and provides templates, instructions, and a sample SBC, plus other materials such as guides for coverage examples.

Language provisions include the requirement that SBCs be provided in a culturally and linguistically appropriate manner. The requirement can be satisfied by following rules for providing claims and appeals notices in such manner as provided in Section 2719 and paragraph (e) of the implementation regulations of the Public Health Service Act (PHS), which tie the term “culturally and linguistically appropriate” to instances where 10% or more of a population in a claimant’s county are literate only in the same non-English language. The Federal Register announcement notes that while the language for most such counties is Spanish, a number of counties where Tagalog, Chinese, and Navajo are the dominant language in Alaska, Arizona, California, New Mexico and Utah are also affected. The Department of Health and Human Services plans to provide translations of the template and other documents in these languages, and other languages may also be addressed.

  • While the PHS Act requires that SBCs be no longer than four pages, the rule clarifies that, given the content, language, and appearance requirements, this means four double-sided pages. Font size may be no smaller than 12-point. Printing may be in color or grayscale.
  • Group plan coverage SBCs may be provided as standalone documents or in combination with other summary materials. When provided with summary materials, SBC information must be intact and prominently displayed at the beginning of the materials and comply with applicable timing requirements.
  • Notice must be provided to enrollees or covered individuals when any terms or coverage in the plan are materially modified in such a way that the SBC would be affected (except when related to renewal or reissuance of coverage). Such notice must be provided at least 60 days prior to the effective date of such modification.
  • Internet addresses must be provided for lists of network providers, prescription drug formulary (where applicable), and the glossary of definitions. A contact phone number must be included for enrollees and policyholders wishing to obtain a paper copy of the uniform glossary (a disclosure that paper copies of the uniform glossary are available is also required).
  • These requirements do not preempt any state requirements that may be stricter, and states are not prevented from imposing additional requirements. To minimize consumer confusion, the Departments encourage and are willing to work with states to harmonize their disclosure requirements with those mandated by the federal government.

While these requirements apply starting in September 2012, the Departments indicate that changes may be made after the first year of implementation.

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