Summary of Benefits and Coverage and Uniform Glossary-Templates, Instructions, and Related Materials Under the Public Health Service Act
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.
Table of Contents Back to Top
DATES: Back to Top
Comment Dates: Comments are due on or before October 21, 2011.
ADDRESSES: Back to Top
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: http://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: RIN1210-AB52.
Comments received by the Department of Labor will be posted without change to http://www.regulations.gov and http://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 http://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: http://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: http://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: Back to Top
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 (http://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 (http://www.cms.hhs.gov/HealthInsReformforConsume/01_Overview.asp) and information on health reform can be found at http://www.healthcare.gov.
SUPPLEMENTARY INFORMATION: Back to Top
I. Introduction Back to Top
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).  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 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.  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. 
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,  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.  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”)  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 http://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.  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 Back to Top
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 http://cciio.cms.gov) the specific information necessary to simulate benefits covered under the plan or policy for the 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),  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.
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 Back to Top
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),  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.)
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,  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 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,  status as a grandfathered health plan,  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.
IV. Paperwork Reduction Act Back to Top
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.
Administrator, Centers for Medicare & Medicaid Services.
Dated: August 9, 2011.
Secretary, Department of Health and Human Services.
V. Appendices Back to Top
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 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 http://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
[FR Doc. 2011-21192 Filed 8-17-11; 11:15 am]
BILLING CODE 4120-01-C
Footnotes Back to Top
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.Back to Context
2. A list of the NAIC working group members can be found at: http://www.naic.org/documents/committees_b_consumer_information_contacts.pdf.Back to Context
3. Records and other information relating to all of the meetings held by the NAIC working group can be found at: http://www.naic.org/committees_b_consumer_information.htm.Back to Context
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.”Back to Context
5. Summaries of this consumer testing are available at: http://www.naic.org/documents/committees_b_consumer_information_101012_ahip_focus_group_summary.pdf; http://www.naic.org/documents/committees_b_consumer_information_110603_ahip_bcbsa_consumer_testing.pdf; http://www.naic.org/documents/committees_b_consumer_information_101014_consumers_union.pdf (a more detailed summary of which is accessible at: http://prescriptionforchange.org/pdf/CU_Consumer_Testing_Report_Dec_2010.pdf); and http://www.naic.org/documents/committees_b_consumer_information_110603_consumers_union_testing.pdf.Back to Context
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).Back to Context
7. National Association of Insurance Commissioners, Consumer Information Working Group, December 17, 2010 Letter to the Secretaries. Available at http://www.naic.org/documents/committees_b_consumer_information_ppaca_letter_to_sebelius.pdf.Back to Context
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.Back to Context
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.Back to Context
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.Back to Context