Excerpt from Professor Jost's post on Health Affairs Blog:

On February 25, 2016 the departments released a proposed revised SBC template, proposed individual and group instructions, and a proposed uniform glossary. The proposed template is shorter than the NAIC-recommended SBC template. The documents are exposed for a thirty-day comment period. They will presumably not be effective for marketplace coverage beginning January 1, 2017, but could be effective for plan years beginning with the second quarter of 2017.

The proposed revised template adopts many of the NAIC stakeholder group recommendations and is a distinct improvement over the original NPRM template. It includes a new question—“Are there services covered before you meet your deductible?”—to identify the growing number of health plans that cover some primary care, generic or preferred drugs, and even specialist services before the deductible applies. These before-the-deductible services are also identified in the common medical events section.

The instructions to the proposed revised template, unlike those that accompanied the NPRM template, require family coverage plans to disclose whether the plan has “embedded” deductibles or out-of-pocket limits (under which family members can meet individual deductibles or out-of-pocket limits before the family deductible or out-of-pocket limit is met), or “non-embedded” deductibles and out-of-pocket limits (where the full family deductible or out-of-pocket limit must be met before any family member benefits).

The proposed revised instructions require the disclosure of tiered networks in response to the front page question, “Will you pay less if you use a network provider?” with more information in the common medical events chart. Plans must make clear which provider tiers are most and least expensive. The SBC warns consumers that they may receive services from out-of-network providers while in in-network facilities and urges consumers to check with their providers to make sure services are covered. Consumers are told that they might receive balance bills from out-of-network providers.

Unlike the current and NPRM versions, the proposed revised template notes that information on the premium is provided separately. The revised template contains somewhat more granular data on pregnancy claims. It contains clearer explanations of the meaning of minimum essential coverage and of the minimum value standard.

The proposed revised instructions require disclosure of certain “core” limitations and exceptions not required by the NPRM instructions, including:

The instructions do provide, however, that when these disclosures would cause the SBC to exceed eight pages, disclosures can be provided by referencing a specific page or section of a plan document, such as the summary plan description, where more information can be found.

Consumers have long complained that it is difficult to tell whether health plans cover abortion or not. Under the proposed revised instructions, qualified health plans offered through the marketplaces are required to disclose whether or not they cover abortion services. Plans that cover excepted abortions (in cases of rape or incest and when the mother’s life is at stake) and non-excepted abortion services must list “abortion” in the covered services box. Plans that exclude all abortions must list “abortion” in the excluded services box. Plans that cover only excepted abortions must list in the excluded services box “abortion (except in cases of rape, incest, or when the life of the mother is endangered)” and may also cross-reference another plan document that more fully describes the exceptions.

Health plans other than qualified health plans are not required to disclose abortion coverage but may do it in the same way. Multi-state plans are subject to separate Office of Personnel Management rules on abortion coverage and disclosure.

Section 2715 requires SBCs to include “a coverage facts label that includes examples to illustrate common benefits scenarios, including pregnancy and serious or chronic medical conditions and related cost sharing.” The proposed revised SBC includes three coverage examples: maternity, diabetes, and a simple fracture. The proposed revised SBC tracks the NAIC stakeholder recommended format for the coverage examples, which is somewhat less misleading and confusing than the NPRM version. It focuses on cost-sharing parameters that would apply to services received for these conditions and on what consumers would spend in cost sharing for these services.

Significantly, the coverage examples are to be calculated by plans that have wellness programs assuming that enrollees are not participating in the wellness program, although the plan can also indicate that costs may be reduced if enrollees do participate. The departments have also revised the coverage example calculator to make it more accurate.

The revised glossary tracks closely the NAIC stakeholder group recommendations rather than the NPRM. The changes are mostly technical and aimed at achieving greater readability or accuracy. In a few instances, however, changed definitions do serve a more substantive purpose, such as clarifying that balance bills are not necessarily consumer obligations and that habilitation services can be medically necessary. The glossary contains helpful illustrations showing how common cost-sharing features work.

The departments seem to have adopted the NAIC stakeholder group’s recommendation that the departments underline all terms used in the SBC that are defined in the glossary and permit insurers and health plans that issue electronic SBCs to hyperlink these terms in the SBC to a federal website where the terms are defined. This should make the glossary much more useful.

The departments provide the SBC and uniform glossary in English, Spanish, Navaho (written and oral) and Tagalog. QHP insurers are also required to provide taglines in the top fifteen languages in their state on the SBC. These taglines are not subject to the otherwise absolute eight page limit.

While the departments by and large followed the NAIC’s template recommendations, they did not adopt them entirely. Most importantly, the proposed revised template drops a cover page that the NAIC stakeholder group added after consumer testing to explain the purpose of the SBC and how to use it. The departments believed that the extra page of explanations would make it too difficult for plans to stay within the eight page limit.

On the whole the proposed revised SBC is a distinct improvement over both the current SBC and the NPRM version. It is unfortunate, however, that consumers in the marketplaces will have to wait until the 2018 open enrollment period for these changes to be put in place.