Summary of Benefits and Coverage Health plans and employers are subject to new Affordable Care Act requirements regarding information provided to members. This brochure helps to explain the obligations of Blue KC, brokers, and employers.
MCM SBCBR-9/12
SUMMARY OF BENEFITS AND COVERAGE OVERVIEW Blue Cross and Blue Shield of Kansas City (Blue KC) wants to make sure you understand Affordable Care Act (ACA) requirements. Effective September 23, 2012, all health plans and employers are subject to new requirements regarding information provided to members through a standardized plan document known as a Summary of Benefits and Coverage (SBC). To ensure consistency, SBCs are created using a standard template and language provided by the Department of Health and Human Services (HHS). The SBC provides answers to commonly asked questions about coverage offered by Blue KC, including deductible amounts, covered services, and cost-sharing amounts for common medical events.
SBC requirements include strict timeframes for dissemination of this information. Blue KC wants to let you know your role in SBC distribution and how to comply with these requirements, since penalties apply for noncompliance, and these penalties can apply to both health plans and employers. For members of groups that hold their open enrollment period prior to the effective date of September 23, 2012, Blue KC will not provide SBCs for the open enrollment. We will, however, post electronic copies of the SBC in the Member File Cabinet on BlueKC.com, beginning September 23, 2012. In addition, members and our customers are welcome to request a paper copy of the SBC any time after September 23, 2012 by calling 1-877-410-6716.
WHAT PLANS ARE AFFECTED? SBC requirements apply to: • Self-funded and insured medical plans • Individual plans • Student health insurance • Expatriate plans (U.S.-based benefits only) • Certain other plan types (e.g., Health Reimbursement Arrangments (HRA), pharmacy, and Employee Assistance Plans (EAP), if considered a group health plan)
SBC requirements do not apply to: • Health Savings Accounts (HSA) • Standalone dental and vision • Flexible Spending Accounts (FSA), in some cases • Certified retiree-only plans
ENSURING COMPLIANCE The actions of Blue KC, our brokers, and our employer group clients ensure that everyone is compliant with this law. We all share the responsibility. To comply, Blue KC must deliver SBCs to insured clients, as well as to members and potential members based on certain events: • Before plan renewal • With enrollment materials or during the enrollment period • To newly eligible employees • After a special enrollment • Before making mid-year changes to medical plans • Upon request
For insured plans, penalties for noncompliance apply to Blue KC and employers. For self-funded plans, penalties apply to employers. Everyone’s actions impact compliance with the law. That’s why it’s important for you to: • Understand the new SBC requirements • Provide required documents within required timeframes • Make timely plan/benefit decisions for new and renewing contracts.
2 | BlueKC.com
GROUPS WITH 100+ EMPLOYEES Blue KC will generate an SBC for all Fully Insured and Cost Plus groups, and will work with self-funded clients to ensure an accurate SBC is available. Blue KC will continue providing our existing benefit summary for a more comprehensive view of benefits being offered.
Requirement and Timeframe Open enrollment and renewals on or after September 23, 2012 • No later than 30 days before the start of the new policy year, reflecting any changes effective for the new policy year where possible
Blue KC Role
Employer Role
Blue KC will generate and provide SBCs to the employer as part of the renewal process. Your marketing representative will manage changes needed to the SBC. Blue KC will include the SBCs with enrollment materials.
Broker Role
Blue KC will rely on the employer to provide SBCs to employees.
Blue KC will ask brokers to help employers finalize benefits before SBCs are generated.
Blue KC will notify applicants on our written 100+ applications that an SBC is available through their employer.
Blue KC will rely on the employer to provide SBCs to the employee applying for coverage.
N/A
Blue KC will generate and provide an SBC to the member behind member login.
Blue KC will rely on the employer to provide an SBC to the special enrollee, upon request.
N/A
Blue KC will generate and provide an SBC when request comes in directly to us by calling 1-877-410-6716.
Blue KC will rely on the employer to provide an SBC if requested directly from the employer within the required timeframe.
Blue KC will ask brokers to assist employer groups in obtaining an SBC if requested by the group.
Blue KC will generate and provide an SBC behind member login.
Blue KC will rely on the employer to provide an SBC to each member.
Blue KC will ask brokers to help employers finalize benefits before the required SBC timeframe.
Blue KC will send a notification to all members that their SBC is available by logging onto our website or a copy can be requested by calling us at 1-877-410-6716. Applying for coverage (e.g., new hire) • No later than 7 business days following the receipt of application for any health insurance policy Special Enrollment Period (subject to HIPAA Special Enrollment) • No later than 90 days from enrollment Upon request • No later than 7 business days from receipt of request Material Modification, as defined by ERISA • No later than 60 days prior to the date on which such change will become effective
3 | BlueKC.com
GROUPS WITH 2-99 EMPLOYEES Blue KC will create an SBC for all Fully Insured groups. Blue KC will continue providing our existing benefit summary for a more comprehensive view of benefits being offered.
Requirement and Timeframe Open enrollment and renewals on or after September 23, 2012 • No later than 30 days before the start of the new policy year, reflecting any changes effective for the new policy year
Applying for coverage (e.g., new hire) • No later than 7 business days following the receipt of application for any health insurance policy Special Enrollment Period (subject to HIPAA Special Enrollment) • No later than 90 days from enrollment Upon request • No later than 7 business days from receipt of request Material Modification, as defined by ERISA • No later than 60 days prior to the date on which such change will become effective New Group Application • No later than 7 business days after application
Blue KC Role
Employer Role
Blue KC will include an SBC with enrollment materials.
Broker Role
Blue KC will rely on the employer to provide SBCs to employees.
Blue KC will ask brokers to help employers finalize benefits before SBC is generated.
Blue KC will notify applicants on our written 2-99 applications that an SBC is available through their employer or at BlueKC.com.
Blue KC will rely on the employer to provide SBC to the employee applying for coverage.
Blue KC will make available SBCs in the BlueQ system for the broker to inform employers and/or applicants of the SBC’s availability and assist them with obtaining a copy.
Blue KC will generate and provide SBC to the member behind member login.
Blue KC will rely on the employer to provide an SBC to the special enrollee, upon request.
N/A
Blue KC will generate and provide SBC when request comes in directly to us at 1-877-410-6716.
Blue KC will rely on the employer to provide an SBC if requested directly from the employer within the required timeframe.
Blue KC will ask brokers to assist employer groups in obtaining an SBC if requested by the group.
Blue KC will generate and provide an SBC behind member login.
Blue KC will rely on the employer to provide an SBC to each member.
Blue KC will ask brokers to help employers finalize benefits before SBC timeframe.
Blue KC will provide SBCs in BlueQ for brokers’ use.
Employer groups will also be able to view an SBC at BlueKC.com.
Blue KC will ask brokers to inform employer groups of the availability of the SBC and assist them in obtaining a copy.
Blue KC will send a notification to all members that their SBC is available by logging onto our website or a copy can be requested by calling 1-877-410-6716.
4 | BlueKC.com
INDIVIDUAL ENROLLMENT Blue KC will create an SBC for each individual policyholder. Individual policyholders can review their contract for a more comprehensive look at plan benefits.
Requirement and Timeframe Upon renewal on or after September 23, 2012 • No later than 30 days before the start of the new policy year, reflecting any changes effective for the new policy year Upon application • No later than 7 business days following the receipt of application for any health insurance policy Upon request • No later than 7 business days
Blue KC Role
Broker Role
Blue KC will notify members that their SBC is available by logging onto BlueKC.com or a copy can be requested by calling us at 1-877-410-6716 through the annual renewal letter process.
N/A
Blue KC will notify applicants on the written direct enrollment application that their SBC is available at BlueKC.com or a copy can be requested by calling us at 1-877-410-6716.
Blue KC will ask brokers to inform individuals of the availability of the SBC, and assist applicants with obtaining an SBC at BlueKC.com.
Blue KC will generate and provide SBC when request comes in directly to us at 1-877-410-6716.
When a request comes directly to brokers, Blue KC will ask the brokers to assist members with obtaining an SBC at BlueKC.com.
5 | BlueKC.com
SBC AT A GLANCE Health plans and employers are subject to new ACA requirements regarding information provided to current and prospective members through a standardized “plain language” SBC. The SBC is created using a standard template and language provided by HHS to ensure consistency. It provides answers to commonly asked questions about coverage offered by Blue KC, including deductible amounts, covered services, and cost-sharing amounts for common medical events.
The ACA also requires that the SBC be made available in select non-English languages (Spanish, Mandarin, Tagalog, and Navajo), upon request. For more information visit the HHS website at: http://cciio.cms.gov/resources/other/index.html#sbcug.
SBC SAMPLE Insurance Company 1: Plan Option 1
Summary of Benefits and Coverage: What this Plan Covers & What it Costs
Coverage Period: 01/01/2013 – 12/31/2013 Coverage for: Individual + Spouse | Plan Type: PPO
This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at www.[insert] or by calling 1-800-[insert]. Important Questions
Answers
Why this Matters:
What is the overall deductible?
You must pay all the costs up to the deductible amount before this plan begins to pay for $500 person / covered services you use. Check your policy or plan document to see when the deductible $1,000 family starts over (usually, but not always, January 1st). See the chart starting on page 2 for how Doesn’t apply to preventive care much you pay for covered services after you meet the deductible.
Are there other deductibles for specific services?
Yes. $300 for prescription drug coverage. There are no other specific deductibles.
Is there an out–of– pocket limit on my expenses?
Yes. For participating providers $2,500 person / $5,000 The out-of-pocket limit is the most you could pay during a coverage period (usually one family year) for your share of the cost of covered services. This limit helps you plan for health For non-participating providers care expenses. $4,000 person / $8,000 family
What is not included in the out–of–pocket limit?
Premiums, balance-billed charges, and health care this plan doesn’t cover.
Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
Is there an overall annual limit on what the plan pays?
No.
The chart starting on page 2 describes any limits on what the plan will pay for specific covered services, such as office visits.
Does this plan use a network of providers?
Yes. See www.[insert].com or call 1-800-[insert] for a list of participating providers.
If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Be aware, your in-network doctor or hospital may use an out-of-network provider for some services. Plans use the term in-network, preferred, or participating for providers in their network. See the chart starting on page 2 for how this plan pays different kinds of providers.
Do I need a referral to see a specialist?
No. You don’t need a referral to You can see the specialist you choose without permission from this plan. see a specialist.
Are there services this plan doesn’t cover?
Yes.
You must pay all of the costs for these services up to the specific deductible amount before this plan begins to pay for these services.
Some of the services this plan doesn’t cover are listed on page 4. See your policy or plan document for additional information about excluded services.
Questions: Call 1-800-[insert] or visit us at www.[insert].com. If you aren’t clear about any of the bolded terms used in this form, see the Glossary. You can view the Glossary at www.[insert] or call 1-800-[insert] to request a copy.
6 | BlueKC.com
OMB Control Numbers 1545-2229, 1210-0147, and 0938-1146
1 of 8
IMPORTANT INFORMATION NONCOMPLIANCE PENALTIES AND GOOD FAITH EFFORT Blue KC and our employer groups face significant financial risk and serious penalties for not complying with the SBC requirements. Willful failure to comply could result in up to a $1,000 fine per plan participant or beneficiary for each failure. In addition, separate penalties may apply that are not specific to the SBC requirements but can be imposed for failure to comply with certain federal requirements.
HHS has announced a non-enforcement period for the first year of applicability. During this time, penalties will not be imposed on plans and issuers that are working diligently and in “good faith” to provide the required SBC content in an appearance that is consistent with the final requirements.
UNIFORM GLOSSARY A plan or issuer must make a uniform glossary available upon request, in either paper or electronic form, within 7 business days after receipt of the request.
Per HHS, penalties will not be imposed for failure to provide the SBC or the uniform glossary if “plans and issuers are working diligently and in good faith to comply.”
The Uniform Glossary can be found by visiting either of the following websites: www.cciio.cms.gov or BlueKC.com.
ADDITIONAL INFORMATION When you support Blue KC, your employer groups and/or members in the generation and delivery of the SBCs, you must meet those same strict requirements and deadlines summarized above and on the government website. Your prompt actions will aid compliance with the regulations and avoid penalties.
Since there are potential penalties involved, we must work together to ensure everyone is compliant. It’s important for us to be sure you understand the requirements. If you have questions, please contact your Blue KC marketing representative.
The information provided is a high level overview related to the Summary of Benefits and Coverage requirement pursuant to the Affordable Care Act, and should not be considered legal or compliance advice. This document does not represent a comprehensive view of the requirements. Information is subject to change. For more information on the regulation and guidance, go to www.dol.gov/ebsa/healthreform. This material is for general health information only and does not constitute legal advice. This information is believed to be accurate as of the production date; however, it is subject to change.
7 | BlueKC.com
BlueKC.com
8 | BlueKC.com
