Much more than a “summary”

PPACA’s uniform explanation of benefits and coverage delayed

While employers had been mandated to comply early next year with proposed Summary of Benefits and Coverage (SBC) rules, a recent Frequently Asked Questions (FAQ) document related to the Patient Protection & Affordable Care Act (PPACA) has rescinded the interim requirement. Indeed, the Departments of Health & Human Services, Labor, and the Treasury (the Departments) have been inundated with comments on the interim regulations, Consequently, their “final” guidance will intend to incorporate that stakeholder feedback, and many expect to see a reasonable effective date that will allow group health plans and health insurance issuers sufficient time to implement…think 2013.

Previously, the Departments and other federal agencies involved had stated that the SBC requirements were to apply “beginning March 23, 2012.”


As currently constituted, the SBC requires individual and group health plans alike to provide a uniform explanation of benefits and coverage to all applicants and enrollees. The intent is twofold: to help consumers compare health insurance coverage options before they enroll, and to facilitate their understanding of coverage after they enroll. The provision applies to all self-insured and fully-insured health plans, regardless of whether they are “grandfathered.”

As mandated, the SBC document must not exceed four double-sided pages, must use only words that are understandable to the average consumer, and must be presented in a culturally and linguistically appropriate manner (i.e. it cannot contain “fine print”). Its content must detail the plan’s premium, coverage features such as exclusions/limits, patient cost-sharing for each essential benefits category, and rules regarding the use of network providers. Finally, the SBC should indicate whether the plan meets standards for minimum coverage. 

AND IN CASE YOU MISSED IT: On Tuesday, December 20, the Supreme Court announced plans to hear oral arguments related to President Obama’s healthcare law. To occur over a three-day span in late March 2012, this pronouncement further confirms expectation that the high court will issue a ruling during the height of the battle for the White House. (Schedule below.)

Monday, March 26: Anti-Injunction Act, 1 hour allotted
Tuesday, March 27: Individual Mandate, 2 hours allotted
Wednesday, March 28: Severability/Medicaid, 2 hours allotted

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