By Tony Wilson
Special to the Citizen
Have you ever had that moment in your career when struck by an epiphany you stopped and thought, "Wow, I should have gone into acting, modeling, finance, computer programming, professional bull riding,"... well, you get my point.
I've often thought I should have gone into hiding, but recently I'm thinking I should have gone into the printing business with all the forms, reports and notices required under the health care reform law. If you think you've seen a lot up to this point, just wait, there's more.
One of the notices carriers and employers are required to provide to employees under health care reform is the Summary of Benefits and Coverage. The intent of the law with regard to the SBC is to make understanding and comparing health plans easier for employees: An admirable goal given the confusing nature sometimes (or most of the time) of the insurance industry.
For group health plans that renewed on or after Sept. 23, 2012, employees should receive an SBC either from the carrier (for fully insured plans) or the employer (for self-insured plans). The SBC is a standardized document with a specific length, font size and information to be included, as outlined below by insurance carrier United HealthCare in one of the most succinct formats I've seen.
The Departments of Health and Human Services, Labor and Treasury consulted with the National Association of Insurance Commissioners to develop standards for providing SBCs. The rules are specific down to the size of the font required for the SBC.
The final rule outlines the required content elements for the SBC. These requirements include: a description of the coverage, including the cost-sharing, for each category of benefits identified by the departments; the exceptions, reductions, or limitations on coverage; the cost-sharing provisions of the coverage, including deductible, coinsurance, and copayment obligations; the renewability and continuation of coverage provisions; a coverage facts label or coverage examples; and a statement that the SBC is only a summary and that the plan document, policy or certificate of insurance should be consulted to determine the governing contractual provisions of the coverage.
Other required elements include: a contact number to call with questions and an Internet web address where a copy of the actual individual coverage policy or group certificate of coverage can be reviewed and obtained, an Internet address (or other contact information) for obtaining a list of the network providers, an Internet address where an individual may find more information about the prescription drug coverage under the plan or coverage, an Internet address where an individual may review the Uniform Glossary, and a disclosure that paper copies of the Uniform Glossary are available; and a uniform format, four double-sided pages in length, and 12-point font.
Typically, employers provide employees with plan benefit summaries that are overviews of the plan design selected and include information about the plan deductible, the office visit copays for primary care physicians and specialists, the tiered or level cost of prescriptions and many other aspects of the plan.
The SBC goes into a little more detail than some benefit summaries I've seen, and the SBC offers a Q&A-type format that makes understanding benefits a little easier. However, nothing replaces a well-informed human resources manager.
If an employer makes a material modification during the plan year that would change the content of the SBC, the law requires that the employer provide a new SBC to employees at least 60 days in advance of the effective date of the change. This applies to mid-year changes only and does not affect changes made in connection with a renewal or reissuance of a plan.
Group health plans (including administrators), and health insurance issuers offering group or individual health insurance coverage, that willfully fail to provide required information will be subject to a fine of not more than $1,000 for each such failure. Each failure to deliver the SBC to an individual constitutes a separate offense under the Act.
While most assume material modifications include benefit reductions, it also includes increases in benefits. Benefit enhancements would include coverage of previously excluded benefits or reduced cost-sharing. Benefit reductions would include increases in premium, increases in out-of-pocket maximums and new pre-certification requirements, just to name a few.
Once the plan is implemented, employees typically receive a Certificate of Coverage with the legalese and details of the plan. The certificate makes Tolstoy's "War and Peace" look like a light read. The certificate is the governing document of the plan.
The information required for distribution to employees and individuals under health care reform certainly can be helpful to individuals and families as they make decisions about coverage, but the information can be overwhelming, too. It is critically important that people take charge of this issue and review the materials provided to them by their carrier or their employer.
Many of us listen to friends and co-workers for advice when it comes to making decisions about our health care coverage. However, when it comes to health care reform, I strongly recommend you lean on your human resources department for information and guidance, or that you get in touch with a local broker for advice.
Questions or comments? Feel free to email me at firstname.lastname@example.org.
Tony L. Wilson is a principal with NUVISION Financial Corporation based in Conyers. NUVISION is a subsidiary of National Financial Partners Corp. (NFP), which provides benefits solutions for companies.