Summary of Benefits and Coverage and Uniform Glossary-Templates, Instructions, and Related Materials Under the Public Health Service Act, 52475-52531 [2011-21192]
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that is consistent with the rules of
paragraph (a)(4) of this section.
(c) Uniform glossary—(1) In general.
A group health plan, and a health
insurance issuer offering group health
insurance coverage, must make
available to participants and
beneficiaries, and a health insurance
issuer offering individual health
insurance coverage must make available
to applicants, policyholders, and
covered dependents, the uniform
glossary described in paragraph (c)(2) of
this section in accordance with the
appearance and format requirements of
paragraphs (c)(3) and (c)(4) of this
section.
(2) Health-coverage-related terms and
medical terms. The uniform glossary
must provide uniform definitions,
specified by the Secretary in guidance,
for the following health-coverage-related
terms and medical terms:
(i) Allowed amount, appeal, balance
billing, co-insurance, complications of
pregnancy, co-payment, deductible,
durable medical equipment, emergency
medical condition, emergency medical
transportation, emergency room care,
emergency services, excluded services,
grievance, habilitation services, health
insurance, home health care, hospice
services, hospitalization, hospital
outpatient care, in-network coinsurance, in-network co-payment,
medically necessary, network, nonpreferred provider, out-of-network coinsurance, out-of-network co-payment,
out-of-pocket limit, physician services,
plan, preauthorization, preferred
provider, premium, prescription drug
coverage, prescription drugs, primary
care physician, primary care provider,
provider, reconstructive surgery,
rehabilitation services, skilled nursing
care, specialist, usual customary and
reasonable (UCR), and urgent care; and
(ii) Such other terms as the Secretary
determines are important to define so
that individuals and employers may
compare and understand the terms of
coverage and medical benefits
(including any exceptions to those
benefits), as specified in guidance.
(3) Appearance. A group health plan,
and a health insurance issuer, must
provide the uniform glossary with the
appearance authorized in guidance,
ensuring that the uniform glossary is
presented in a uniform format and
utilizes terminology understandable by
the average plan enrollee (or, in the case
of individual market coverage, an
average individual covered under a
health insurance policy).
(4) Form and manner. A plan or issuer
must make the uniform glossary
described in this paragraph (c) available
upon request, in either paper or
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electronic form (as requested), within
seven days of the request. (Under the
rules of paragraph (a) of this section, the
form authorized in guidance for the SBC
will disclose to participants,
beneficiaries, and individuals covered
under an individual policy their rights
to request a copy of the uniform
glossary.)
(d) Preemption. For purposes of this
section, the provisions of section 2724
of the PHS Act continue to apply with
respect to preemption of State law. In
addition, with respect to the standards
for providing an SBC required under
paragraph (a) of this section, State laws
that require a health insurance issuer to
provide an SBC that supplies less
information than required under
paragraph (a) of this section are
preempted.
(e) Failure to provide. A health
insurance issuer or a non-Federal
governmental health plan that willfully
fails to provide information required
under this section is subject to a fine of
not more than $1,000 for each such
failure. A failure with respect to each
covered individual constitutes a
separate offense for purposes of this
paragraph (e). HHS will enforce these
provisions in a manner consistent with
45 CFR 150.101 through 150.465.
(f) Applicability date. This section is
applicable beginning March 23, 2012.
See § 147.140(d) of this chapter,
providing that this section applies to
grandfathered health plans.
[FR Doc. 2011–21193 Filed 8–17–11; 11:15 am]
BILLING CODE 4120–01–P
DEPARTMENT OF THE TREASURY
Internal Revenue Service
26 CFR Part 54
DEPARTMENT OF LABOR
Employee Benefits Security
Administration
29 CFR Part 2590
DEPARTMENT OF HEALTH AND
HUMAN SERVICES
[CMS–9982–NC]
45 CFR Part 147
Summary of Benefits and Coverage
and Uniform Glossary—Templates,
Instructions, and Related Materials
Under the Public Health Service Act
Internal Revenue Service,
Department of the Treasury; Employee
Benefits Security Administration,
AGENCY:
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Department of Labor; Centers for
Medicare & Medicaid Services,
Department of Health and Human
Services.
ACTION: Solicitation of comments.
The Departments of the
Health and Human Services, Labor, and
the Treasury (the Departments) are
simultaneously publishing in the
Federal Register this document and
proposed regulations (2011 proposed
regulations) under the Patient Protection
and Affordable Care Act to implement
the disclosure for group health plans
and health insurance issuers of the
summary of benefits and coverage (SBC)
and the uniform glossary. This
document proposes a template for an
SBC; instructions, sample language, and
a guide for coverage examples
calculations to be used in completing
the template; and a uniform glossary
that would satisfy the disclosure
requirements under section 2715 of the
Public Health Service (PHS) Act.
Comments are invited on these
materials.
SUMMARY:
Comment Dates: Comments are
due on or before October 21, 2011.
ADDRESSES: Written comments may be
submitted to any of the addresses
specified below. Any comment that is
submitted to any Department will be
shared with the other Departments.
Please do not submit duplicates.
All comments will be made available
to the public. Warning: Do not include
any personally identifiable information
(such as name, address, or other contact
information) or confidential business
information that you do not want
publicly disclosed. All comments are
posted on the Internet exactly as
received, and can be retrieved by most
Internet search engines. No deletions,
modifications, or redactions will be
made to the comments received, as they
are public records. Comments may be
submitted anonymously.
Department of Labor. Comments to
the Department of Labor, identified by
RIN 1210–AB52, by one of the following
methods:
• Federal eRulemaking Portal: https://
www.regulations.gov. Follow the
instructions for submitting comments.
• E-mail: E–OHPSCA2715.EBSA
@dol.gov.
• Mail or Hand Delivery: Office of
Health Plan Standards and Compliance
Assistance, Employee Benefits Security
Administration, Room N–5653, U.S.
Department of Labor, 200 Constitution
Avenue NW., Washington, DC 20210,
Attention: RIN 1210–AB52.
Comments received by the
Department of Labor will be posted
DATES:
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without change to https://
www.regulations.gov and https://
www.dol.gov/ebsa, and available for
public inspection at the Public
Disclosure Room, N–1513, Employee
Benefits Security Administration, 200
Constitution Avenue, NW., Washington,
DC 20210.
Department of Health and Human
Services. In commenting, please refer to
file code CMS–9982–NC. Because of
staff and resource limitations, we cannot
accept comments by facsimile (FAX)
transmission.
You may submit comments in one of
four ways (please choose only one of the
ways listed):
1. Electronically. You may submit
electronic comments on this regulation
to https://www.regulations.gov. Follow
the instructions under the ‘‘More Search
Options’’ tab.
2. By regular mail. You may mail
written comments to the following
address ONLY: Centers for Medicare &
Medicaid Services, Department of
Health and Human Services, Attention:
CMS–9982–NC, P.O. Box 8016,
Baltimore, MD 21244–1850.
Please allow sufficient time for mailed
comments to be received before the
close of the comment period.
3. By express or overnight mail. You
may send written comments to the
following address ONLY: Centers for
Medicare & Medicaid Services,
Department of Health and Human
Services, Attention: CMS–9982–NC,
Mail Stop C4–26–05, 7500 Security
Boulevard, Baltimore, MD 21244–1850.
4. By hand or courier. If you prefer,
you may deliver (by hand or courier)
your written comments before the close
of the comment period to either of the
following addresses:
a. For delivery in Washington, DC—
Centers for Medicare & Medicaid
Services, Department of Health and
Human Services, Room 445–G, Hubert
H. Humphrey Building, 200
Independence Avenue, SW.,
Washington, DC 20201.
(Because access to the interior of the
Hubert H. Humphrey Building is not
readily available to persons without
Federal government identification,
commenters are encouraged to leave
their comments in the CMS drop slots
located in the main lobby of the
building. A stamp-in clock is available
for persons wishing to retain a proof of
filing by stamping in and retaining an
extra copy of the comments being filed.)
b. For delivery in Baltimore, MD—
Centers for Medicare & Medicaid
Services, Department of Health and
Human Services, 7500 Security
Boulevard, Baltimore, MD 21244–1850.
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If you intend to deliver your
comments to the Baltimore address,
please call (410) 786–9994 in advance to
schedule your arrival with one of our
staff members.
Comments mailed to the addresses
indicated as appropriate for hand or
courier delivery may be delayed and
received after the comment period.
Submission of comments on
paperwork requirements. You may
submit comments on this document’s
paperwork requirements by following
the instructions at the end of the
‘‘Collection of Information
Requirements’’ section in this
document.
Inspection of Public Comments: All
comments received before the close of
the comment period are available for
viewing by the public, including any
personally identifiable or confidential
business information that is included in
a comment. We post all comments
received before the close of the
comment period on the following Web
site as soon as possible after they have
been received: https://
www.regulations.gov. Follow the search
instructions on that Web site to view
public comments.
Comments received timely will also
be available for public inspection as
they are received, generally beginning
approximately three weeks after
publication of a document, at the
headquarters of the Centers for Medicare
& Medicaid Services, 7500 Security
Boulevard, Baltimore, Maryland 21244,
Monday through Friday of each week
from 8:30 a.m. to 4 p.m. EST. To
schedule an appointment to view public
comments, phone 1–800–743–3951.
Internal Revenue Service. Comments
to the IRS, identified by REG–140038–
10, by one of the following methods:
• Federal eRulemaking Portal: https://
www.regulations.gov. Follow the
instructions for submitting comments.
• Mail: CC:PA:LPD:PR (REG–140038–
10), room 5205, Internal Revenue
Service, P.O. Box 7604, Ben Franklin
Station, Washington, DC 20044.
• Hand or courier delivery: Monday
through Friday between the hours of 8
a.m. and 4 p.m. to: CC:PA:LPD:PR
(REG–140038–10), Courier’s Desk,
Internal Revenue Service, 1111
Constitution Avenue, NW., Washington
DC 20224.
All submissions to the IRS will be
open to public inspection and copying
in room 1621, 1111 Constitution
Avenue, NW., Washington, DC from 9
a.m. to 4 p.m.
FOR FURTHER INFORMATION CONTACT:
Amy Turner or Heather Raeburn,
Employee Benefits Security
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Administration, Department of Labor, at
(202) 693–8335; Karen Levin, Internal
Revenue Service, Department of the
Treasury, at (202) 622–6080; Jennifer
Libster or Padma Shah, Centers for
Medicare & Medicaid Services,
Department of Health and Human
Services, at (301) 492–4252.
Customer Service Information:
Individuals interested in obtaining
information from the Department of
Labor concerning employment-based
health coverage laws may call the EBSA
Toll-Free Hotline at 1–866–444–EBSA
(3272) or visit the Department of Labor’s
Web site (https://www.dol.gov/ebsa). In
addition, information from HHS on
private health insurance for consumers
can be found on the Centers for
Medicare & Medicaid Services (CMS)
Web site (https://www.cms.hhs.gov/
HealthInsReformforConsume/
01_Overview.asp) and information on
health reform can be found at https://
www.healthcare.gov.
SUPPLEMENTARY INFORMATION:
I. Introduction
The Departments of Health and
Human Services (HHS), Labor, and the
Treasury (the Departments) are taking a
phased approach to issuing regulations
and guidance implementing the revised
Public Health Service Act (PHS Act)
sections 2701 through 2719A and
related provisions of the Patient
Protection and Affordable Care Act
(Affordable Care Act).1 Section 2715 of
the PHS Act directs the Departments to
develop standards for use by a group
health plan and a health insurance
issuer in compiling and providing a
summary of benefits and coverage (SBC)
that ‘‘accurately describes the benefits
and coverage under the applicable plan
or coverage.’’ Section 2715 of the PHS
Act also directs the Departments to
provide for the development of a
uniform glossary. The statute directs the
Departments, in developing such
standards, to ‘‘consult with the National
Association of Insurance
Commissioners’’ (referred to in this
document as the ‘‘NAIC’’), ‘‘a working
group composed of representatives of
health insurance-related consumer
advocacy organizations, health
insurance issuers, health care
professionals, patient advocates
including those representing
1 The Affordable Care Act also adds section
715(a)(1) to the Employee Retirement Income
Security Act (ERISA) and section 9815(a)(1) to the
Internal Revenue Code (the Code) to incorporate the
provisions of part A of title XXVII of the PHS Act
into ERISA and the Code, and make them
applicable to group health plans, and health
insurance issuers providing health insurance
coverage in connection with group health plans.
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individuals with limited English
proficiency, and other qualified
individuals.’’
As part of this required consultation,
the NAIC convened the Consumer
Information (B) Subgroup (NAIC
working group), comprised of a diverse
group of stakeholders.2 This working
group met frequently each month for
over one year while developing its
recommendations. The NAIC working
group created two subgroups—one
focused on developing a uniform
glossary of health insurance and
medical terms and the other focused on
developing standards for the SBC. All
drafts were discussed and agreed to by
the entire NAIC working group and then
submitted to the full NAIC membership
for a vote to submit the drafts as
recommendations to the Departments.
Throughout the process, NAIC working
group draft documents and meeting
notes were displayed on the NAIC’s
Web site for public review, and several
interested parties filed formal
comments. In addition to participation
from the NAIC working group members,
conference calls and in-person meetings
were open to other interested parties
and individuals and provided an
opportunity for non-member feedback.
The NAIC indicates that stakeholders
from a diverse pool of backgrounds
participated in working group
conference calls.3
As a result of this process, the NAIC
working group recommended use of a
uniform SBC template, as well as a
uniform glossary, for the individual and
group insurance markets. In developing
these recommendations, the draft SBC
template, including the coverage
examples, and the draft uniform
glossary underwent consumer testing,4
sponsored by both consumer and
insurance industry groups. These tests
were intended to assist in determining
necessary adjustments to ensure the
final product was consumer friendly.5
2 A list of the NAIC working group members can
be found at: https://www.naic.org/documents/
committees_b_consumer_information_contacts.pdf.
3 Records and other information relating to all of
the meetings held by the NAIC working group can
be found at: https://www.naic.org/committees_
b_consumer_information.htm.
4 The NAIC consulted readability experts and
conducted consumer testing. The SBC format was
designed to enhance to consumer understanding
and usability. For example, use of vocabulary, such
as ‘‘don’t’’ verses ‘‘do not’’ reflects intentional
design based on feedback from consumer testing.
These format choices reflect in part, the NAIC’s
efforts to address the statutory requirement that the
form be ‘‘culturally and linguistically appropriate.’’
5 Summaries of this consumer testing are
available at: https://www.naic.org/documents/
committees_b_consumer_information_101012_
ahip_focus_group_summary.pdf; https://www.naic.
org/documents/committees_b_consumer_
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The Departments have received
transmittals from the NAIC that include
a recommended template for the SBC
(referred to in this document as the
‘‘SBC template’’) 6 with instructions,
samples, and a guide for coverage
examples calculations to be used in
completing the SBC template. The NAIC
transmittals also included a
recommended uniform glossary of
coverage and medical terms (referred to
in this document as the ‘‘uniform
glossary’’). The SBC template and
uniform glossary include modifications
made by the NAIC working group in
response to the results of extensive
consumer testing.
The 2011 proposed regulations and
this document follow the
recommendations made by the NAIC
and incorporate the documents drafted
by the NAIC, including the SBC
template (with instructions, sample
language, and a guide for coverage
examples calculations to be used in
completing the SBC template) and the
uniform glossary. The Appendices do
not include a sample coverage example
calculation for breast cancer in the
individual market that was transmitted
by the NAIC. Upon review, it appeared
that some of the data in the example
might be subject to copyright protection.
Moreover, the sample coverage example
calculation provided by the NAIC was
limited to breast cancer in the
individual market and did not address
the other two coverage examples—
maternity coverage and diabetes.
Finally, particular coding information
and pricing information included in the
sample would change annually, which
would result in the data included in the
sample becoming outdated relatively
quickly. Accordingly, HHS is publishing
on its Web site (at https://cciio.cms.gov)
the coding and pricing information
necessary to perform coverage example
calculations for all three coverage
examples. HHS will update this
information annually.
Instead of proposing possible changes
to the NAIC’s proposed SBC template
and related materials at this time, this
document proposes to incorporate the
information_110603_ahip_bcbsa_consumer_
testing.pdf; https://www.naic.org/documents/
committees_b_consumer_information_
101014_consumers_union.pdf (a more detailed
summary of which is accessible at: https://
prescriptionforchange.org/pdf/CU_Consumer_
Testing_Report_Dec_2010.pdf); and https://
www.naic.org/documents/committees_b_consumer_
information_110603_consumers_union_testing.pdf.
6 In their materials, the NAIC uses the phrase
‘‘Summary of Coverage’’ to describe the SBC
template. However, the Departments use the term
‘‘Summary of Benefits and Coverage’’ in the
proposed regulations and this document. Both of
these terms are meant to refer to the same document
(located in Appendix A–1 of this document).
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NAIC working group’s recommended
materials as transmitted (with the
exception of the sample coverage
example, explained above), and invites
public comment. The Departments
recognize that changes to the SBC
template may be appropriate to
accommodate various types of plan and
coverage designs, to provide additional
information to individuals, or to
improve the efficacy of the disclosures
recommended by the NAIC. In addition,
the SBC template and related
documents were drafted by the NAIC
primarily for use by health insurance
issuers.7 The NAIC states in its
transmittal letter that additional
modifications may be needed for some
group health plans. Consequently,
comments are requested on these issues
specifically and on the SBC template,
sample completed SBC, instructions for
both group health plan coverage and
individual health insurance coverage,
sample language for the ‘‘Why this
Matters’’ section of the SBC, guide for
coverage examples calculations, and on
the uniform glossary generally. After the
public comment period, the
Departments will finalize these
documents. Consistent with PHS Act
section 2715(c), the Departments will
periodically review and update these
documents as appropriate, taking into
account public comments.
II. Proposal
This document proposes an SBC
template (with instructions, samples,
and a guide for coverage examples
calculations to be used in completing
the SBC template), and the uniform
glossary, to comply with the disclosure
requirements of PHS Act section 2715,
as authorized by the Departments
pursuant to paragraph (a)(4) of the 2011
proposed regulations. The SBC
template, sample completed SBC,
instructions for both group health plan
coverage and individual health
insurance coverage, sample language for
the ‘‘Why This Matters’’ section of the
SBC, guide for coverage examples
calculations, and uniform glossary are
identical to the documents transmitted
by the NAIC. These items are contained
in the Appendices to this document.
In addition to the materials in the
Appendices that are proposed in this
document, HHS is providing (at https://
cciio.cms.gov) the specific information
necessary to simulate benefits covered
under the plan or policy for the
7 National Association of Insurance
Commissioners, Consumer Information Working
Group, December 17, 2010 Letter to the Secretaries.
Available at https://www.naic.org/documents/
committees_b_consumer_information_ppaca_letter_
to_sebelius.pdf.
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coverage examples portion of the SBC
(including specific medical items and
services, dates of service, billing codes,
and allowed charges for each claim in
the three specified benefits scenarios).
HHS will update this information
annually on its Web site. The
Departments propose that plans and
issuers are not required to update their
coverage examples for SBCs provided
before the date that is 90 days after the
date that HHS provides this updated
information. That is, 90 days after HHS
updates the information, SBCs that are
otherwise required to be provided under
paragraph (a) of the proposed rules
should take into account the new
information when providing coverage
examples. For example, if HHS releases
updated information on September 15 of
a year, SBCs required to be provided on
or after December 14 of that year under
the rules of paragraph (a) of the
proposed rules would need to include
coverage examples calculated using the
new information. However, these
updates alone will not be considered a
material modification under paragraph
(b) of the 2011 proposed regulations.
Comments are invited on this
information as well, including the
annual update provision. The preamble
to the 2011 proposed regulations
contains a request for comment
regarding various approaches to
providing the coverage examples.
Commenters addressing the requirement
to provide updated coverage examples
are encouraged to consider how updates
would be made to the coverage
examples under these various
approaches and what additional
instructions should be added to address
updates and a possible phased-in
approach to implementation discussed
in the preamble to the 2011 proposed
regulations.
With respect to the element of the
SBC regarding a statement about
whether a plan or coverage provides
minimum essential coverage (as defined
under section 5000A(f) of the Code) and
whether the plan’s or coverage’s share of
the total allowed costs of benefits
provided under the plan or coverage
meets applicable minimum value
requirements (minimum essential
coverage statement),8 because this
content is not relevant until other
elements of the Affordable Care Act are
implemented, this statement is not in
8 PHS Act section 2715(b)(3)(G) provides that this
statement must indicate whether the plan or
coverage (1) provides minimum essential coverage
(as defined under section 5000A(f) of the Code) and
(2) ensures that the plan’s or coverage’s share of the
total allowed costs of benefits provided under the
plan or coverage is not less than 60 percent of such
costs.
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the NAIC recommendations. For the
same reason, and as discussed more
fully in the preamble to the 2011
proposed regulations, the minimum
essential coverage statement is not
required to be in the SBC until the plan
or coverage is required to provide an
SBC with respect to coverage beginning
on or after January 1, 2014. As provided
in the preamble to the 2011 proposed
regulations, comments are requested on
how employers might provide the
information included in the minimum
essential coverage statement and other
plan-level reporting in a manner that
minimizes duplication and burden.
In addition, the SBC template
recommended by the NAIC and located
in Appendix A–1 of this document
includes Web sites for individuals to
access the uniform glossary, for
information about prescription drug
coverage, and for information about the
plan or coverage provider network. The
Departments note, however, these Web
sites are not working Web sites. Plans
and issuers would need to modify this
aspect of the SBC template to include
relevant, working Web addresses (for
the uniform glossary, this may be the
Web address of either the Department of
Labor or HHS Web site, or on the plan’s
or issuer’s own Web site). The
Departments invite comment on
whether this statement in the SBC
template regarding the electronically
available uniform glossary should be
modified to include a statement that the
uniform glossary is available in paper
form upon request.
III. Solicitation of Comments
The Departments solicit comments
generally on the SBC template and
related documents and the uniform
glossary included in the Appendices, as
well as on specific issues set forth below
(including on what modifications, if
any, are needed for group health plans
to use the SBC template).
The NAIC stated in the December
2010 transmittal letter that the working
group intentionally designed the layout
and color of the SBC template based on
consumer testing to make the document
more readable and to facilitate
comparison of different plan and
coverage options. The Departments
recognize, however, that color printing
may be costly for some plans and
issuers and therefore propose that a plan
or issuer will be compliant if it uses
either the color version (available on the
Web sites of the Departments of Labor
and HHS),9 as recommended by the
NAIC, or the grayscale version (included
9 See https://www.dol.gov/ebsa or https://
cciio.cms.gov.
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in the Appendices to this document). In
addition, the Departments note that
while the NAIC-recommended SBC
template is only three double-sided
pages, the Departments are proposing
that a completed SBC may be four
double-sided pages in length. The SBC
template reserves space to ensure that a
plan or issuer with different benefit
designs (such as multiple, tiered
provider networks) could provide all the
necessary information, and that
additional coverage examples could be
added in the future, within four doublesided pages. (See the preamble to the
2011 proposed regulations for a request
for comment regarding various
approaches to providing the coverage
examples.)
The Departments are interested in any
general comments regarding the
proposed SBC template, sample
completed SBC, instructions for both
group health plan coverage and
individual health insurance coverage,
sample language for the ‘‘Why This
Matters’’ section of the SBC, guide for
coverage examples calculations, and
uniform glossary. In making this request
for comment, the Departments note that
the purpose of PHS Act section 2715 is
to provide individuals and plan
participants with a brief summary of
plan or policy benefits and coverage so
that they may more easily compare
health care coverage and better
understand the terms of coverage (or
exceptions to the coverage). The SBC is
intended to assist individuals
purchasing coverage in the individual
market in comparing the benefits and
coverage of different individual policies
offered by insurance issuers. Likewise,
the SBC is intended to assist employees
who are offered group coverage to
compare among different employerprovided health care options or to
compare their employer’s options with
other coverage for which they may be
eligible, such as a spouse’s or
dependent’s offer of employer-provided
health care coverage, a former
employer’s COBRA continuation
coverage,10 or a policy on the individual
market.
In order to make it as easy as possible
for individuals to understand the terms
of their own coverage and compare
coverage and benefits efficiently and
accurately, the statute provides for, and
the NAIC recognized the importance of,
presenting the SBC in a uniform format.
We invite comments on how this
statutory requirement should be
10 As defined in 26 CFR 54.9801–2, 29 CFR
2590.701–2, and 45 CFR 144.103, COBRA means
Title X of the Consolidated Omnibus Budget
Reconciliation Act of 1985, as amended.
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applied, including the nature and extent
of the uniformity that should be
required in the specific language of the
SBC and the manner and sequence in
which the information in the SBC is
presented. We ask that any comments
proposing that flexibility be permitted
in aspects of the presentation of the SBC
explicitly address the potential positive
or negative effects on individuals’
ability to effectively compare benefits
and coverage among and across
individual policies and group health
plans.
The Departments also invite
comments on the following specific
issues:
1. The SBC template is intended to be
used by all types of plan or coverage
designs. The Departments are interested
in comments related to issues that may
arise from the use of this template for
different types of plan or coverage
designs (for example, designs using
tiered provider networks or group
health plans that may use multiple
issuers or service providers to provide
or administer different categories of
benefits within a benefit package).
2. The Departments are interested in
comments regarding any modifications
needed for use by group health plans
(e.g., with respect to disclosure
regarding cost of coverage and changes
in terminology required for self-insured
plans, such as use of the term ‘‘plan
year’’ instead of ‘‘policy period’’).
3. The Departments are interested in
comments regarding whether the
content of the SBC should require
inclusion of additional information,
such as information regarding any
preexisting condition exclusion under
the plan or policy,11 status as a
grandfathered health plan,12 or other
information that might be important for
individuals to know about their
coverage and how the SBC template
could be modified to ensure effective
disclosure of these additional elements,
while respecting the statutory
formatting requirements. For example,
comments are requested on whether a
simplified reporting method, such as a
checkbox, could be used to disclose
preexisting condition exclusions and
grandfather status.
4. The fourth page of the SBC
template includes a list of services that
plans and issuers must indicate as either
excluded or covered in the ‘‘Excluded
Services & Other Covered Services’’
chart. The Departments solicit
comments on whether services should
be added or removed from this list, as
well as whether the disclosure stating
that the list is not complete is adequate.
5. The SBC template includes a
disclosure on the first page indicating to
consumers that the SBC is not the actual
policy and does not include all of the
coverage details found in the actual
policy. The Departments solicit
comments on whether this disclosure is
adequate.
The uniform glossary is also included
in Appendix E of this document. The
Departments propose that plans and
issuers cannot make any modifications
to this glossary. The uniform glossary
was developed to facilitate and enhance
consumer comprehension and is not
intended to provide legal or contractual
definitions that necessarily apply
accurately, without modification, to
every plan or coverage. The NAIC
consumer testing found that certain
terms relating to cost-sharing provisions
were particularly difficult for consumers
to understand. As a result, the NAIC
developed diagrams to accompany the
textual definitions of these terms. The
Departments solicit comments on the
uniform glossary, including its terms
and definitions, and whether other
terms should be added to the glossary,
as well as whether any of the terms
would be considered inaccurate or
misleading based on a particular plan or
coverage design.
Comments are also invited on the
standards set forth in the 2011 proposed
regulations. To comment on the 2011
proposed regulations, see the comment
section of the 2011 proposed
regulations, published elsewhere in this
issue of the Federal Register.
11 Note: The general notice of preexisting
condition exclusion and the individual notice of
preexisting condition exclusion at 26 CFR 54.9801–
3(c) and (e), 29 CFR 2590.701–3(c) and (e), and 45
CFR 146.111(c) and (e), were published as part of
the Departments’ HIPAA portability regulations on
December 30, 2004, 69 FR 78720.
12 Note: Under paragraph (a)(2) of the
Departments’ interim final regulations regarding
status as a grandfathered health plan, to maintain
grandfather status, group health plans and health
insurance coverage must include a statement in any
plan materials describing the benefits provided that
the plan or coverage believes it is a grandfathered
health plan. Model language is provided. See 26
CFR 54.9815–1251T(a)(2), 29 CFR 2590.715–
1251(a)(2), and 45 CFR 147.140(a)(2), published in
the Federal Register on June 17, 2010, 75 FR 34538.
IV. Paperwork Reduction Act
According to the Paperwork
Reduction Act of 1995 (Pub. L. 104–13)
(PRA), no persons are required to
respond to a collection of information
unless such collection displays a valid
OMB control number. The Department
notes that a Federal agency cannot
conduct or sponsor a collection of
information unless it is approved by
OMB under the PRA, and displays a
currently valid OMB control number,
and the public is not required to
respond to a collection of information
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unless it displays a currently valid OMB
control number. See 44 U.S.C. 3507.
Also, notwithstanding any other
provisions of law, no person shall be
subject to penalty for failing to comply
with a collection of information if the
collection of information does not
display a currently valid OMB control
number. See 44 U.S.C. 3512.
This document relates to the
information collection request (ICR)
contained in a proposed regulation
titled ‘‘Summary of Benefits and
Coverage and the Uniform Glossary,’’
which is published elsewhere in today’s
issue of the Federal Register. For a
discussion of the hour and cost burden
associated with the ICR, please see the
notice of proposed rulemaking.
Sarah Hall Ingram,
Acting Deputy Commissioner for Services and
Enforcement, Internal Revenue Service.
Signed this 15th day of August, 2011.
Phyllis C. Borzi,
Assistant Secretary, Employee Benefits
Security Administration, Department of
Labor.
Dated: July 28, 2011.
Donald Berwick,
Administrator, Centers for Medicare &
Medicaid Services.
Dated: August 9, 2011.
Kathleen Sebelius,
Secretary, Department of Health and Human
Services.
V. Appendices
Table of Contents
A. Summary of Benefits and Coverage (SBC)
Appendix A–1. SBC Template
Appendix A–2. Sample Completed SBC
(Individual Health Insurance Coverage)
B. Instructions for Completing the SBC
Appendix B–1. Instructions—Group Health
Plan Coverage
Appendix B–2. Instructions—Individual
Health Insurance Coverage
C. Sample Language—Why This Matters
section of SBC (Page 1)
Appendix C–1. Why This Matters language
for ‘‘Yes’’ Answers
Appendix C–2. Why This Matters language
for ‘‘No’’ Answers
D. Coverage Examples Calculations
Appendix D. Guide for Coverage Examples
Calculations
E. Uniform Glossary
Appendix E. Uniform Glossary of Coverage
and Medical Terms
Overview of Appendices
As stated earlier in this document, the
NAIC transmitted the work of the NAIC
Working Group to the Departments. The
Appendices to this document include
the SBC documents drafted by the NAIC
in their entirety, with the exception of
the sample coverage example
calculation for breast cancer in the
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individual market, as explained earlier
in this document.
Appendix A–1 contains an SBC
template, as developed by the NAIC
Working Group. The NAIC Working
Group incorporated all of their
recommendations contained in the
multiple transmittals to the Departments
over the last several months in their
final recommended SBC template.
Appendix A–2 contains a sample
completed SBC, using information for a
sample individual health insurance
policy. While the sample completed
SBC may not align perfectly with the
instructions in every way, the document
is useful in providing a general
illustration of a completed SBC for a
sample insurance policy.
Appendices B–1 and B–2 contain
instructions for group health coverage
and individual health insurance
coverage, respectively, to use in
completing the SBC template. The
Departments are publishing the sample
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completed SBC and the instructions to
facilitate compliance with the
requirements of the 2011 proposed
regulations and this document.
The SBC instructions include
language that must be used when
completing the ‘‘Why This Matters’’
column on the first page of the SBC
template. Depending on the design of
the policy or plan, there are two
language options provided in
Appendices C–1 (for when the answer
in the applicable row is ‘‘yes’’) and C–
2 (for when the answer in the applicable
row is ‘‘no’’). Appendices C–1 and C–2
provide an example of how this column
will look when populated with the
required language, as applicable
depending upon the terms of the plan or
coverage.
Appendix D contains a guide for use
by a plan or issuer in compiling
information related to the coverage
examples. This document, together with
information provided in Microsoft Excel
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format by HHS at https://cciio.cms.gov,
comprises all the information necessary
to perform coverage example
calculations for all three coverage
examples. HHS will update the
information on its Web site annually.
With respect to these annual updates,
the Departments propose that 90 days
after HHS updates the information,
SBCs that are otherwise required to be
provided under paragraph (a) of the
2011 proposed rules would take into
account the new information when
providing coverage examples.
Finally, Appendix E contains the
Uniform Glossary of Health Insurance
and Medical Terms.
The Departments invite comments on
all of the documents in the Appendices
to this document and their use in
relation to the requirements of the 2011
proposed regulations and this
document.
BILING CODE 4120–01–P
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]]>Agencies
[Federal Register Volume 76, Number 162 (Monday, August 22, 2011)]
[Proposed Rules]
[Pages 52475-52531]
From the Federal Register Online via the Government Printing Office [www.gpo.gov]
[FR Doc No: 2011-21192]
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DEPARTMENT OF THE TREASURY
Internal Revenue Service
26 CFR Part 54
DEPARTMENT OF LABOR
Employee Benefits Security Administration
29 CFR Part 2590
DEPARTMENT OF HEALTH AND HUMAN SERVICES
[CMS-9982-NC]
45 CFR Part 147
Summary of Benefits and Coverage and Uniform Glossary--Templates,
Instructions, and Related Materials Under the Public Health Service Act
AGENCY: Internal Revenue Service, Department of the Treasury; Employee
Benefits Security Administration, Department of Labor; Centers for
Medicare & Medicaid Services, Department of Health and Human Services.
ACTION: Solicitation of comments.
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SUMMARY: The Departments of the Health and Human Services, Labor, and
the Treasury (the Departments) are simultaneously publishing in the
Federal Register this document and proposed regulations (2011 proposed
regulations) under the Patient Protection and Affordable Care Act to
implement the disclosure for group health plans and health insurance
issuers of the summary of benefits and coverage (SBC) and the uniform
glossary. This document proposes a template for an SBC; instructions,
sample language, and a guide for coverage examples calculations to be
used in completing the template; and a uniform glossary that would
satisfy the disclosure requirements under section 2715 of the Public
Health Service (PHS) Act. Comments are invited on these materials.
DATES: Comment Dates: Comments are due on or before October 21, 2011.
ADDRESSES: Written comments may be submitted to any of the addresses
specified below. Any comment that is submitted to any Department will
be shared with the other Departments. Please do not submit duplicates.
All comments will be made available to the public. Warning: Do not
include any personally identifiable information (such as name, address,
or other contact information) or confidential business information that
you do not want publicly disclosed. All comments are posted on the
Internet exactly as received, and can be retrieved by most Internet
search engines. No deletions, modifications, or redactions will be made
to the comments received, as they are public records. Comments may be
submitted anonymously.
Department of Labor. Comments to the Department of Labor,
identified by RIN 1210-AB52, by one of the following methods:
Federal eRulemaking Portal: https://www.regulations.gov.
Follow the instructions for submitting comments.
E-mail: E-OHPSCA2715.EBSA@dol.gov.
Mail or Hand Delivery: Office of Health Plan Standards and
Compliance Assistance, Employee Benefits Security Administration, Room
N-5653, U.S. Department of Labor, 200 Constitution Avenue NW.,
Washington, DC 20210, Attention: RIN 1210-AB52.
Comments received by the Department of Labor will be posted
[[Page 52476]]
without change to https://www.regulations.gov and https://www.dol.gov/ebsa, and available for public inspection at the Public Disclosure
Room, N-1513, Employee Benefits Security Administration, 200
Constitution Avenue, NW., Washington, DC 20210.
Department of Health and Human Services. In commenting, please
refer to file code CMS-9982-NC. Because of staff and resource
limitations, we cannot accept comments by facsimile (FAX) transmission.
You may submit comments in one of four ways (please choose only one
of the ways listed):
1. Electronically. You may submit electronic comments on this
regulation to https://www.regulations.gov. Follow the instructions under
the ``More Search Options'' tab.
2. By regular mail. You may mail written comments to the following
address ONLY: Centers for Medicare & Medicaid Services, Department of
Health and Human Services, Attention: CMS-9982-NC, P.O. Box 8016,
Baltimore, MD 21244-1850.
Please allow sufficient time for mailed comments to be received
before the close of the comment period.
3. By express or overnight mail. You may send written comments to
the following address ONLY: Centers for Medicare & Medicaid Services,
Department of Health and Human Services, Attention: CMS-9982-NC, Mail
Stop C4-26-05, 7500 Security Boulevard, Baltimore, MD 21244-1850.
4. By hand or courier. If you prefer, you may deliver (by hand or
courier) your written comments before the close of the comment period
to either of the following addresses:
a. For delivery in Washington, DC--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, Room 445-G, Hubert
H. Humphrey Building, 200 Independence Avenue, SW., Washington, DC
20201.
(Because access to the interior of the Hubert H. Humphrey Building
is not readily available to persons without Federal government
identification, commenters are encouraged to leave their comments in
the CMS drop slots located in the main lobby of the building. A stamp-
in clock is available for persons wishing to retain a proof of filing
by stamping in and retaining an extra copy of the comments being
filed.)
b. For delivery in Baltimore, MD--Centers for Medicare & Medicaid
Services, Department of Health and Human Services, 7500 Security
Boulevard, Baltimore, MD 21244-1850.
If you intend to deliver your comments to the Baltimore address,
please call (410) 786-9994 in advance to schedule your arrival with one
of our staff members.
Comments mailed to the addresses indicated as appropriate for hand
or courier delivery may be delayed and received after the comment
period.
Submission of comments on paperwork requirements. You may submit
comments on this document's paperwork requirements by following the
instructions at the end of the ``Collection of Information
Requirements'' section in this document.
Inspection of Public Comments: All comments received before the
close of the comment period are available for viewing by the public,
including any personally identifiable or confidential business
information that is included in a comment. We post all comments
received before the close of the comment period on the following Web
site as soon as possible after they have been received: https://www.regulations.gov. Follow the search instructions on that Web site to
view public comments.
Comments received timely will also be available for public
inspection as they are received, generally beginning approximately
three weeks after publication of a document, at the headquarters of the
Centers for Medicare & Medicaid Services, 7500 Security Boulevard,
Baltimore, Maryland 21244, Monday through Friday of each week from 8:30
a.m. to 4 p.m. EST. To schedule an appointment to view public comments,
phone 1-800-743-3951.
Internal Revenue Service. Comments to the IRS, identified by REG-
140038-10, by one of the following methods:
Federal eRulemaking Portal: https://www.regulations.gov.
Follow the instructions for submitting comments.
Mail: CC:PA:LPD:PR (REG-140038-10), room 5205, Internal
Revenue Service, P.O. Box 7604, Ben Franklin Station, Washington, DC
20044.
Hand or courier delivery: Monday through Friday between
the hours of 8 a.m. and 4 p.m. to: CC:PA:LPD:PR (REG-140038-10),
Courier's Desk, Internal Revenue Service, 1111 Constitution Avenue,
NW., Washington DC 20224.
All submissions to the IRS will be open to public inspection and
copying in room 1621, 1111 Constitution Avenue, NW., Washington, DC
from 9 a.m. to 4 p.m.
FOR FURTHER INFORMATION CONTACT: Amy Turner or Heather Raeburn,
Employee Benefits Security Administration, Department of Labor, at
(202) 693-8335; Karen Levin, Internal Revenue Service, Department of
the Treasury, at (202) 622-6080; Jennifer Libster or Padma Shah,
Centers for Medicare & Medicaid Services, Department of Health and
Human Services, at (301) 492-4252.
Customer Service Information: Individuals interested in obtaining
information from the Department of Labor concerning employment-based
health coverage laws may call the EBSA Toll-Free Hotline at 1-866-444-
EBSA (3272) or visit the Department of Labor's Web site (https://www.dol.gov/ebsa). In addition, information from HHS on private health
insurance for consumers can be found on the Centers for Medicare &
Medicaid Services (CMS) Web site (https://www.cms.hhs.gov/HealthInsReformforConsume/01_Overview.asp) and information on health
reform can be found at https://www.healthcare.gov.
SUPPLEMENTARY INFORMATION:
I. Introduction
The Departments of Health and Human Services (HHS), Labor, and the
Treasury (the Departments) are taking a phased approach to issuing
regulations and guidance implementing the revised Public Health Service
Act (PHS Act) sections 2701 through 2719A and related provisions of the
Patient Protection and Affordable Care Act (Affordable Care Act).\1\
Section 2715 of the PHS Act directs the Departments to develop
standards for use by a group health plan and a health insurance issuer
in compiling and providing a summary of benefits and coverage (SBC)
that ``accurately describes the benefits and coverage under the
applicable plan or coverage.'' Section 2715 of the PHS Act also directs
the Departments to provide for the development of a uniform glossary.
The statute directs the Departments, in developing such standards, to
``consult with the National Association of Insurance Commissioners''
(referred to in this document as the ``NAIC''), ``a working group
composed of representatives of health insurance-related consumer
advocacy organizations, health insurance issuers, health care
professionals, patient advocates including those representing
[[Page 52477]]
individuals with limited English proficiency, and other qualified
individuals.''
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\1\ The Affordable Care Act also adds section 715(a)(1) to the
Employee Retirement Income Security Act (ERISA) and section
9815(a)(1) to the Internal Revenue Code (the Code) to incorporate
the provisions of part A of title XXVII of the PHS Act into ERISA
and the Code, and make them applicable to group health plans, and
health insurance issuers providing health insurance coverage in
connection with group health plans.
---------------------------------------------------------------------------
As part of this required consultation, the NAIC convened the
Consumer Information (B) Subgroup (NAIC working group), comprised of a
diverse group of stakeholders.\2\ This working group met frequently
each month for over one year while developing its recommendations. The
NAIC working group created two subgroups--one focused on developing a
uniform glossary of health insurance and medical terms and the other
focused on developing standards for the SBC. All drafts were discussed
and agreed to by the entire NAIC working group and then submitted to
the full NAIC membership for a vote to submit the drafts as
recommendations to the Departments. Throughout the process, NAIC
working group draft documents and meeting notes were displayed on the
NAIC's Web site for public review, and several interested parties filed
formal comments. In addition to participation from the NAIC working
group members, conference calls and in-person meetings were open to
other interested parties and individuals and provided an opportunity
for non-member feedback. The NAIC indicates that stakeholders from a
diverse pool of backgrounds participated in working group conference
calls.\3\
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\2\ A list of the NAIC working group members can be found at:
https://www.naic.org/documents/committees_b_consumer_information_contacts.pdf.
\3\ Records and other information relating to all of the
meetings held by the NAIC working group can be found at: https://www.naic.org/committees_b_consumer_information.htm.
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As a result of this process, the NAIC working group recommended use
of a uniform SBC template, as well as a uniform glossary, for the
individual and group insurance markets. In developing these
recommendations, the draft SBC template, including the coverage
examples, and the draft uniform glossary underwent consumer testing,\4\
sponsored by both consumer and insurance industry groups. These tests
were intended to assist in determining necessary adjustments to ensure
the final product was consumer friendly.\5\ The Departments have
received transmittals from the NAIC that include a recommended template
for the SBC (referred to in this document as the ``SBC template'') \6\
with instructions, samples, and a guide for coverage examples
calculations to be used in completing the SBC template. The NAIC
transmittals also included a recommended uniform glossary of coverage
and medical terms (referred to in this document as the ``uniform
glossary''). The SBC template and uniform glossary include
modifications made by the NAIC working group in response to the results
of extensive consumer testing.
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\4\ The NAIC consulted readability experts and conducted
consumer testing. The SBC format was designed to enhance to consumer
understanding and usability. For example, use of vocabulary, such as
``don't'' verses ``do not'' reflects intentional design based on
feedback from consumer testing. These format choices reflect in
part, the NAIC's efforts to address the statutory requirement that
the form be ``culturally and linguistically appropriate.''
\5\ Summaries of this consumer testing are available at: https://www.naic.org/documents/committees_b_consumer_information_101012_ahip_focus_group_summary.pdf; https://www.naic.org/documents/committees_b_consumer_information_110603_ahip_bcbsa_consumer_testing.pdf; https://www.naic.org/documents/committees_b_consumer_information_101014_consumers_union.pdf
(a more detailed summary of which is accessible at: https://prescriptionforchange.org/pdf/CU_Consumer_Testing_Report_Dec_2010.pdf); and https://www.naic.org/documents/committees_b_consumer_information_110603_consumers_union_testing.pdf.
\6\ In their materials, the NAIC uses the phrase ``Summary of
Coverage'' to describe the SBC template. However, the Departments
use the term ``Summary of Benefits and Coverage'' in the proposed
regulations and this document. Both of these terms are meant to
refer to the same document (located in Appendix A-1 of this
document).
---------------------------------------------------------------------------
The 2011 proposed regulations and this document follow the
recommendations made by the NAIC and incorporate the documents drafted
by the NAIC, including the SBC template (with instructions, sample
language, and a guide for coverage examples calculations to be used in
completing the SBC template) and the uniform glossary. The Appendices
do not include a sample coverage example calculation for breast cancer
in the individual market that was transmitted by the NAIC. Upon review,
it appeared that some of the data in the example might be subject to
copyright protection. Moreover, the sample coverage example calculation
provided by the NAIC was limited to breast cancer in the individual
market and did not address the other two coverage examples--maternity
coverage and diabetes. Finally, particular coding information and
pricing information included in the sample would change annually, which
would result in the data included in the sample becoming outdated
relatively quickly. Accordingly, HHS is publishing on its Web site (at
https://cciio.cms.gov) the coding and pricing information necessary to
perform coverage example calculations for all three coverage examples.
HHS will update this information annually.
Instead of proposing possible changes to the NAIC's proposed SBC
template and related materials at this time, this document proposes to
incorporate the NAIC working group's recommended materials as
transmitted (with the exception of the sample coverage example,
explained above), and invites public comment. The Departments recognize
that changes to the SBC template may be appropriate to accommodate
various types of plan and coverage designs, to provide additional
information to individuals, or to improve the efficacy of the
disclosures recommended by the NAIC. In addition, the SBC template and
related documents were drafted by the NAIC primarily for use by health
insurance issuers.\7\ The NAIC states in its transmittal letter that
additional modifications may be needed for some group health plans.
Consequently, comments are requested on these issues specifically and
on the SBC template, sample completed SBC, instructions for both group
health plan coverage and individual health insurance coverage, sample
language for the ``Why this Matters'' section of the SBC, guide for
coverage examples calculations, and on the uniform glossary generally.
After the public comment period, the Departments will finalize these
documents. Consistent with PHS Act section 2715(c), the Departments
will periodically review and update these documents as appropriate,
taking into account public comments.
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\7\ National Association of Insurance Commissioners, Consumer
Information Working Group, December 17, 2010 Letter to the
Secretaries. Available at https://www.naic.org/documents/committees_b_consumer_information_ppaca_letter_to_sebelius.pdf.
---------------------------------------------------------------------------
II. Proposal
This document proposes an SBC template (with instructions, samples,
and a guide for coverage examples calculations to be used in completing
the SBC template), and the uniform glossary, to comply with the
disclosure requirements of PHS Act section 2715, as authorized by the
Departments pursuant to paragraph (a)(4) of the 2011 proposed
regulations. The SBC template, sample completed SBC, instructions for
both group health plan coverage and individual health insurance
coverage, sample language for the ``Why This Matters'' section of the
SBC, guide for coverage examples calculations, and uniform glossary are
identical to the documents transmitted by the NAIC. These items are
contained in the Appendices to this document.
In addition to the materials in the Appendices that are proposed in
this document, HHS is providing (at https://cciio.cms.gov) the specific
information necessary to simulate benefits covered under the plan or
policy for the
[[Page 52478]]
coverage examples portion of the SBC (including specific medical items
and services, dates of service, billing codes, and allowed charges for
each claim in the three specified benefits scenarios). HHS will update
this information annually on its Web site. The Departments propose that
plans and issuers are not required to update their coverage examples
for SBCs provided before the date that is 90 days after the date that
HHS provides this updated information. That is, 90 days after HHS
updates the information, SBCs that are otherwise required to be
provided under paragraph (a) of the proposed rules should take into
account the new information when providing coverage examples. For
example, if HHS releases updated information on September 15 of a year,
SBCs required to be provided on or after December 14 of that year under
the rules of paragraph (a) of the proposed rules would need to include
coverage examples calculated using the new information. However, these
updates alone will not be considered a material modification under
paragraph (b) of the 2011 proposed regulations. Comments are invited on
this information as well, including the annual update provision. The
preamble to the 2011 proposed regulations contains a request for
comment regarding various approaches to providing the coverage
examples. Commenters addressing the requirement to provide updated
coverage examples are encouraged to consider how updates would be made
to the coverage examples under these various approaches and what
additional instructions should be added to address updates and a
possible phased-in approach to implementation discussed in the preamble
to the 2011 proposed regulations.
With respect to the element of the SBC regarding a statement about
whether a plan or coverage provides minimum essential coverage (as
defined under section 5000A(f) of the Code) and whether the plan's or
coverage's share of the total allowed costs of benefits provided under
the plan or coverage meets applicable minimum value requirements
(minimum essential coverage statement),\8\ because this content is not
relevant until other elements of the Affordable Care Act are
implemented, this statement is not in the NAIC recommendations. For the
same reason, and as discussed more fully in the preamble to the 2011
proposed regulations, the minimum essential coverage statement is not
required to be in the SBC until the plan or coverage is required to
provide an SBC with respect to coverage beginning on or after January
1, 2014. As provided in the preamble to the 2011 proposed regulations,
comments are requested on how employers might provide the information
included in the minimum essential coverage statement and other plan-
level reporting in a manner that minimizes duplication and burden.
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\8\ PHS Act section 2715(b)(3)(G) provides that this statement
must indicate whether the plan or coverage (1) provides minimum
essential coverage (as defined under section 5000A(f) of the Code)
and (2) ensures that the plan's or coverage's share of the total
allowed costs of benefits provided under the plan or coverage is not
less than 60 percent of such costs.
---------------------------------------------------------------------------
In addition, the SBC template recommended by the NAIC and located
in Appendix A-1 of this document includes Web sites for individuals to
access the uniform glossary, for information about prescription drug
coverage, and for information about the plan or coverage provider
network. The Departments note, however, these Web sites are not working
Web sites. Plans and issuers would need to modify this aspect of the
SBC template to include relevant, working Web addresses (for the
uniform glossary, this may be the Web address of either the Department
of Labor or HHS Web site, or on the plan's or issuer's own Web site).
The Departments invite comment on whether this statement in the SBC
template regarding the electronically available uniform glossary should
be modified to include a statement that the uniform glossary is
available in paper form upon request.
III. Solicitation of Comments
The Departments solicit comments generally on the SBC template and
related documents and the uniform glossary included in the Appendices,
as well as on specific issues set forth below (including on what
modifications, if any, are needed for group health plans to use the SBC
template).
The NAIC stated in the December 2010 transmittal letter that the
working group intentionally designed the layout and color of the SBC
template based on consumer testing to make the document more readable
and to facilitate comparison of different plan and coverage options.
The Departments recognize, however, that color printing may be costly
for some plans and issuers and therefore propose that a plan or issuer
will be compliant if it uses either the color version (available on the
Web sites of the Departments of Labor and HHS),\9\ as recommended by
the NAIC, or the grayscale version (included in the Appendices to this
document). In addition, the Departments note that while the NAIC-
recommended SBC template is only three double-sided pages, the
Departments are proposing that a completed SBC may be four double-sided
pages in length. The SBC template reserves space to ensure that a plan
or issuer with different benefit designs (such as multiple, tiered
provider networks) could provide all the necessary information, and
that additional coverage examples could be added in the future, within
four double-sided pages. (See the preamble to the 2011 proposed
regulations for a request for comment regarding various approaches to
providing the coverage examples.)
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\9\ See https://www.dol.gov/ebsa or https://cciio.cms.gov.
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The Departments are interested in any general comments regarding
the proposed SBC template, sample completed SBC, instructions for both
group health plan coverage and individual health insurance coverage,
sample language for the ``Why This Matters'' section of the SBC, guide
for coverage examples calculations, and uniform glossary. In making
this request for comment, the Departments note that the purpose of PHS
Act section 2715 is to provide individuals and plan participants with a
brief summary of plan or policy benefits and coverage so that they may
more easily compare health care coverage and better understand the
terms of coverage (or exceptions to the coverage). The SBC is intended
to assist individuals purchasing coverage in the individual market in
comparing the benefits and coverage of different individual policies
offered by insurance issuers. Likewise, the SBC is intended to assist
employees who are offered group coverage to compare among different
employer-provided health care options or to compare their employer's
options with other coverage for which they may be eligible, such as a
spouse's or dependent's offer of employer-provided health care
coverage, a former employer's COBRA continuation coverage,\10\ or a
policy on the individual market.
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\10\ As defined in 26 CFR 54.9801-2, 29 CFR 2590.701-2, and 45
CFR 144.103, COBRA means Title X of the Consolidated Omnibus Budget
Reconciliation Act of 1985, as amended.
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In order to make it as easy as possible for individuals to
understand the terms of their own coverage and compare coverage and
benefits efficiently and accurately, the statute provides for, and the
NAIC recognized the importance of, presenting the SBC in a uniform
format. We invite comments on how this statutory requirement should be
[[Page 52479]]
applied, including the nature and extent of the uniformity that should
be required in the specific language of the SBC and the manner and
sequence in which the information in the SBC is presented. We ask that
any comments proposing that flexibility be permitted in aspects of the
presentation of the SBC explicitly address the potential positive or
negative effects on individuals' ability to effectively compare
benefits and coverage among and across individual policies and group
health plans.
The Departments also invite comments on the following specific
issues:
1. The SBC template is intended to be used by all types of plan or
coverage designs. The Departments are interested in comments related to
issues that may arise from the use of this template for different types
of plan or coverage designs (for example, designs using tiered provider
networks or group health plans that may use multiple issuers or service
providers to provide or administer different categories of benefits
within a benefit package).
2. The Departments are interested in comments regarding any
modifications needed for use by group health plans (e.g., with respect
to disclosure regarding cost of coverage and changes in terminology
required for self-insured plans, such as use of the term ``plan year''
instead of ``policy period'').
3. The Departments are interested in comments regarding whether the
content of the SBC should require inclusion of additional information,
such as information regarding any preexisting condition exclusion under
the plan or policy,\11\ status as a grandfathered health plan,\12\ or
other information that might be important for individuals to know about
their coverage and how the SBC template could be modified to ensure
effective disclosure of these additional elements, while respecting the
statutory formatting requirements. For example, comments are requested
on whether a simplified reporting method, such as a checkbox, could be
used to disclose preexisting condition exclusions and grandfather
status.
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\11\ Note: The general notice of preexisting condition exclusion
and the individual notice of preexisting condition exclusion at 26
CFR 54.9801-3(c) and (e), 29 CFR 2590.701-3(c) and (e), and 45 CFR
146.111(c) and (e), were published as part of the Departments' HIPAA
portability regulations on December 30, 2004, 69 FR 78720.
\12\ Note: Under paragraph (a)(2) of the Departments' interim
final regulations regarding status as a grandfathered health plan,
to maintain grandfather status, group health plans and health
insurance coverage must include a statement in any plan materials
describing the benefits provided that the plan or coverage believes
it is a grandfathered health plan. Model language is provided. See
26 CFR 54.9815-1251T(a)(2), 29 CFR 2590.715-1251(a)(2), and 45 CFR
147.140(a)(2), published in the Federal Register on June 17, 2010,
75 FR 34538.
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4. The fourth page of the SBC template includes a list of services
that plans and issuers must indicate as either excluded or covered in
the ``Excluded Services & Other Covered Services'' chart. The
Departments solicit comments on whether services should be added or
removed from this list, as well as whether the disclosure stating that
the list is not complete is adequate.
5. The SBC template includes a disclosure on the first page
indicating to consumers that the SBC is not the actual policy and does
not include all of the coverage details found in the actual policy. The
Departments solicit comments on whether this disclosure is adequate.
The uniform glossary is also included in Appendix E of this
document. The Departments propose that plans and issuers cannot make
any modifications to this glossary. The uniform glossary was developed
to facilitate and enhance consumer comprehension and is not intended to
provide legal or contractual definitions that necessarily apply
accurately, without modification, to every plan or coverage. The NAIC
consumer testing found that certain terms relating to cost-sharing
provisions were particularly difficult for consumers to understand. As
a result, the NAIC developed diagrams to accompany the textual
definitions of these terms. The Departments solicit comments on the
uniform glossary, including its terms and definitions, and whether
other terms should be added to the glossary, as well as whether any of
the terms would be considered inaccurate or misleading based on a
particular plan or coverage design.
Comments are also invited on the standards set forth in the 2011
proposed regulations. To comment on the 2011 proposed regulations, see
the comment section of the 2011 proposed regulations, published
elsewhere in this issue of the Federal Register.
IV. Paperwork Reduction Act
According to the Paperwork Reduction Act of 1995 (Pub. L. 104-13)
(PRA), no persons are required to respond to a collection of
information unless such collection displays a valid OMB control number.
The Department notes that a Federal agency cannot conduct or sponsor a
collection of information unless it is approved by OMB under the PRA,
and displays a currently valid OMB control number, and the public is
not required to respond to a collection of information unless it
displays a currently valid OMB control number. See 44 U.S.C. 3507.
Also, notwithstanding any other provisions of law, no person shall be
subject to penalty for failing to comply with a collection of
information if the collection of information does not display a
currently valid OMB control number. See 44 U.S.C. 3512.
This document relates to the information collection request (ICR)
contained in a proposed regulation titled ``Summary of Benefits and
Coverage and the Uniform Glossary,'' which is published elsewhere in
today's issue of the Federal Register. For a discussion of the hour and
cost burden associated with the ICR, please see the notice of proposed
rulemaking.
Sarah Hall Ingram,
Acting Deputy Commissioner for Services and Enforcement, Internal
Revenue Service.
Signed this 15th day of August, 2011.
Phyllis C. Borzi,
Assistant Secretary, Employee Benefits Security Administration,
Department of Labor.
Dated: July 28, 2011.
Donald Berwick,
Administrator, Centers for Medicare & Medicaid Services.
Dated: August 9, 2011.
Kathleen Sebelius,
Secretary, Department of Health and Human Services.
V. Appendices
Table of Contents
A. Summary of Benefits and Coverage (SBC)
Appendix A-1. SBC Template
Appendix A-2. Sample Completed SBC (Individual Health Insurance
Coverage)
B. Instructions for Completing the SBC
Appendix B-1. Instructions--Group Health Plan Coverage
Appendix B-2. Instructions--Individual Health Insurance Coverage
C. Sample Language--Why This Matters section of SBC (Page 1)
Appendix C-1. Why This Matters language for ``Yes'' Answers
Appendix C-2. Why This Matters language for ``No'' Answers
D. Coverage Examples Calculations
Appendix D. Guide for Coverage Examples Calculations
E. Uniform Glossary
Appendix E. Uniform Glossary of Coverage and Medical Terms
Overview of Appendices
As stated earlier in this document, the NAIC transmitted the work
of the NAIC Working Group to the Departments. The Appendices to this
document include the SBC documents drafted by the NAIC in their
entirety, with the exception of the sample coverage example calculation
for breast cancer in the
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individual market, as explained earlier in this document.
Appendix A-1 contains an SBC template, as developed by the NAIC
Working Group. The NAIC Working Group incorporated all of their
recommendations contained in the multiple transmittals to the
Departments over the last several months in their final recommended SBC
template.
Appendix A-2 contains a sample completed SBC, using information for
a sample individual health insurance policy. While the sample completed
SBC may not align perfectly with the instructions in every way, the
document is useful in providing a general illustration of a completed
SBC for a sample insurance policy.
Appendices B-1 and B-2 contain instructions for group health
coverage and individual health insurance coverage, respectively, to use
in completing the SBC template. The Departments are publishing the
sample completed SBC and the instructions to facilitate compliance with
the requirements of the 2011 proposed regulations and this document.
The SBC instructions include language that must be used when
completing the ``Why This Matters'' column on the first page of the SBC
template. Depending on the design of the policy or plan, there are two
language options provided in Appendices C-1 (for when the answer in the
applicable row is ``yes'') and C-2 (for when the answer in the
applicable row is ``no''). Appendices C-1 and C-2 provide an example of
how this column will look when populated with the required language, as
applicable depending upon the terms of the plan or coverage.
Appendix D contains a guide for use by a plan or issuer in
compiling information related to the coverage examples. This document,
together with information provided in Microsoft Excel format by HHS at
https://cciio.cms.gov, comprises all the information necessary to
perform coverage example calculations for all three coverage examples.
HHS will update the information on its Web site annually. With respect
to these annual updates, the Departments propose that 90 days after HHS
updates the information, SBCs that are otherwise required to be
provided under paragraph (a) of the 2011 proposed rules would take into
account the new information when providing coverage examples.
Finally, Appendix E contains the Uniform Glossary of Health
Insurance and Medical Terms.
The Departments invite comments on all of the documents in the
Appendices to this document and their use in relation to the
requirements of the 2011 proposed regulations and this document.
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[FR Doc. 2011-21192 Filed 8-17-11; 11:15 am]
BILLING CODE 4120-01-C
