This Employer Webinar Series program This Employer Webinar Series - - PowerPoint PPT Presentation
This Employer Webinar Series program This Employer Webinar Series program is presented by Spencer Fane Britt & Browne LLP in conjunction with United Benefit Advisors is presented by Spencer Fane Britt & Browne LLP in conjunction with
Kansas City Omaha Overland Park
www.spencerfane.com www.ubabenefits.com
Chadron J. Patton Julia M. Vander Weele
April 17, 2012
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Health Care Reform legislation created
Consistent format intended to allow plan
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Final regulations issued
Regulations include template
24 additional FAQs issued March 19, 2012
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Applies to:
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Original effective date was March 23, 2012
For participants and beneficiaries who enroll
For all others (including new hires and
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During the first year that SBC requirements
The Departments’ goal is to achieve:
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Applies to “group health plans”
Counseling under EAP
Biometric screenings in wellness program
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Does not apply to:
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Provided under a separate
Otherwise not an integral part of group
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Health FSAs that are funded solely through
If employer contribution is either less than
If not “excepted benefit” same rules as
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HRAs are generally considered “group
Stand-alone HRA must provide its own SBC “Integrated” HRA can combine SBC for
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SBCs must satisfy specific requirements
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SBCs must:
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Employers do not have to provide separate
Same rule applies to separate cost-sharing
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SBCs may be provided either on a stand-
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SBCs must be provided:
Same standard for providing appeals notices
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If SBCs are provided in US counties in
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The currently affected counties include:
The full list of counties may be accessed at: http://www.cciio.cms.gov/resources/factsheets/clas-data.html
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Uniform definitions of standard insurance
Description of the coverage, including cost-
Exceptions, reductions, and limits on
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Cost-sharing provisions, including
Renewability and continuation of coverage
Examples of common benefits scenarios
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For coverage beginning on or after January
A statement that:
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Contact information, such as:
Internet address or similar contact
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Internet address or similar contact
A uniform glossary, including:
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SBCs do not need to include:
SBCs are not required to include a
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Insured plans may need to comply with state
If the required information is in addition to
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Regulations allow the Departments to
However, the compliance guidance includes
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The coverage examples include:
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SBCs need not summarize coverage for
Expatriate plans or their insurers can
If an expatriate plan provides coverage
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The Departments have provided a template
For an example of a sample completed SBC
Authorized for use only with respect to
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Important Questions Answers Why this Matters: What is the overall deductible?
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Are there other deductibles for specific services?
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Is there an out–of– pocket limit on my expenses?
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What is not included in the
Is there an overall annual limit on what the plan pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn’t cover? 33
The form language and formatting in the
Departments indicated that:
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In some cases, plan terms that must be
If this occurs, the plan or insurer must
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The SBC template requires plans or insurers
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Health care reform requires SBCs to include
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The regulations adopt a two-part approach
Be made available to participants and beneficiaries in connection with the SBC
Satisfy the appearance and form requirements for SBCs
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Includes definitions of insurance, medical
Provides simple, descriptive definitions
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Self-funded plans
Fully insured plans
If one complies, both comply
If neither comply, both liable
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Carve-Out Arrangements (pharmacy benefit
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SBC must be distributed to:
COBRA qualifying event does not, itself, trigger SBC requirement, but during open enrollment period, COBRA beneficiary has same right to SBC as an active employee
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Insurers to plan sponsor:
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Plan to Participants/Beneficiaries:
With initial enrollment materials
If none, no later than first day of eligibility
For special enrollees, within 90 days of enrollment (same as SPD)
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Plan to Participants/Beneficiaries:
If renewal requires written application (or opportunity to change coverage), with written application materials
If renewal is automatic (and no opportunity to change coverage), at least 30 days prior to the first day of the new plan year
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Mid-year changes to SBC that constitute
“Material modification” = change that would
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Distribution within workplace may not be
Single SBC sent by mail to
Multiple SBCs must be sent if beneficiary is
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For current enrollees, must satisfy ERISA
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For eligible but not enrolled participants and
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Fine of up to $1,000 Each failure to provide an SBC is a separate
Excise tax for group health
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Three federal agencies share enforcement:
As a result, enforcement mechanisms and
More guidance is expected
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Coordinate with insurers and TPAs Determine number of SBCs that must be
Prepare and/or review SBC Distribute
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Kansas City Omaha Overland Park
www.spencerfane.com www.ubabenefits.com
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Thank you for your participation in the Employer Webinar Series. This program, has been approved for 1.5 (General) recertification credit hours tow ard PHR, SPHR and GPHR To obtain a recording of this presentation, or to register for future presentations, contact your local UBA Member Firm.