HHS Issues Additional Information for Simulating Coverage Examples in SBCs under the ACA | Practical Law

HHS Issues Additional Information for Simulating Coverage Examples in SBCs under the ACA | Practical Law

The US Department of Health and Human Services has issued several Excel spreadsheets for use in simulating coverage examples as part of the summary of benefits and coverage disclosures required under the Affordable Care Act (ACA).

HHS Issues Additional Information for Simulating Coverage Examples in SBCs under the ACA

by PLC Employee Benfits & Executive Compensation
Published on 30 Aug 2011 • USA (National/Federal)
The US Department of Health and Human Services has issued several Excel spreadsheets for use in simulating coverage examples as part of the summary of benefits and coverage disclosures required under the Affordable Care Act (ACA).
The US Department of Health and Human Services (HHS) has issued several Excel spreadsheets for use in simulating coverage examples as part of the summary of benefits and coverage (SBC) disclosures required under the Affordable Care Act (ACA). The spreadsheets, available through the DOL website, supplement proposed regulations implementing the SBC requirement, that were jointly issued by HHS and the Departments of Labor and Treasury (the Departments) in August 2011 (for more information on the proposed regulations, see Legal Update, Proposed Regulations for Summary of Benefits and Coverage Disclosures). In addition to the proposed regulations, the Departments provided a proposed:
  • Template for the SBC.
  • Guide for coverage examples calculations (with instructions and sample language).
  • Uniform glossary.
An SBC must include coverage examples that illustrate benefits provided under the plan or coverage for common benefits scenarios (for example, pregnancy). A benefits scenario is a hypothetical situation:
  • Consisting of a sample treatment plan for a specified medical condition and time period.
  • Based on recognized clinical practice guidelines.
The benefits scenario is intended to:
  • Simulate the plan's or insurer's processing of claims under the scenario.
  • Illustrate costs that a participant or beneficiary can expect to share with the plan or coverage.
According to HHS, plans or insurers will eventually be able to create benefits scenarios using automated systems for each benefits package they offer. For now, however, coverage example calculations may need to be prepared manually, for example using Excel.
The proposed regulations indicated that additional guidance would specify the types of services, dates of service and related information for each claim in the benefits scenario. The new Excel spreadsheets, which provide this guidance, include a blank benefits scenario template, and completed scenarios for breast cancer, diabetes and maternity. Related narratives contain hypothetical treatment summaries for each of the three scenarios. The scenarios include:
  • A brief description of major services related to the condition (for example, in the maternity scenario, routine obstetric care).
  • Sample care costs and related categories (for example, hospital charges for baby and mother).
  • Standard assumptions (for example, that all services addressed are deemed medically necessary).
  • Specific medical condition information, including dates of service, diagnosis and billing codes, and allowed charges associated with each scenario.

Webinar on Summaries of Benefits and Coverage under the ACA

Be the first to learn about complying with the four-page summaries requirement by attending our free webinar, Summaries of Benefits and Coverage under the ACA: Your Guide to the New Requirements, presented by Practical Law Company on Wednesday, September 21, 2011 at 1:00 pm ET.