Health Care Reform News for Employers

The Blue Shield Health Reform Update will keep you up-to-date with the latest information on the Affordable Care Act (ACA), with a focus on how health reform implementation will impact your company, your employees, and your relationship with Blue Shield.


Health Reform Update - April, 2012

This month’s Health Reform Update provides new information on the subjects below:

Summary of Benefits and Coverage Update

Here is an overview of the Summary of Benefits and Coverage mandate, key changes to the mandate in recently issued final regulations by the Department of Health and Human Services (HHS), and how the mandate will impact employer groups and members.

Overview of the regulation

The Affordable Care Act (ACA) requires that all health carriers provide uniform coverage documentation to help consumers understand their coverage and make “apples-to-apples” comparisons of plan options when purchasing new coverage.
Requirements include:

  • Summary of Benefits and Coverage (SBC), a summary describing plan benefits, cost sharing, and limitations.

  • Coverage Examples included with the SBC, which illustrates an average customer’s costs based on a specific plan’s benefits for common medical scenarios.

  • Glossary, a standard document with definitions of common medical and insurance terms.

  • Notification to the members from the carriers whenever there is a material modification to a benefit, known as a Notice of Modification.

Key changes from the interim regulation

  • The final regulation must be implemented for new and renewing group health plans with open enrollment periods beginning on or after September 23, 2012. For disclosure of SBCs to individuals and dependents in the individual market, these requirements are applicable beginning on September 23, 2012. The original implementation date was March 23, 2012.

  • Premium information is no longer required to be disclosed.

  • In situations where the SBC cannot be provided 30 days in advance of the first day of the new policy year — for instance, where the issuer and the purchaser have not yet finalized the terms of coverage for the new policy year (e.g., on renewal) — the rule allows some flexibility on timing for delivery.

  • Previously, special enrollees (those for whom a special enrollment event has occurred) were required to receive an SBC writing 7 days of a request for enrollment. They now must receive the SBC within 90 days.

  • Two coverage examples are required with the SBC, compared to the three coverage examples required previously.

  • The SBC can be provided in combination with other summary materials as long as the SBC is prominently displayed in the beginning.

Which plans are subject to this mandate?

The requirement applies to all health coverage: individual and group plans and self-funded (ASO) — including dental and vision plans offered as part of a medical plan or as a rider to a medical plan.

It does not apply to stand-alone dental and vision plans, or to Medicare Advantage or Medicare Supplemental plans.

When are plans required to distribute the SBC?

The SBC must be provided to employers, employees, and enrollees when the following events occur:

  • Upon application submission

  • By first day of coverage (if there are changes)

  • Upon renewal

  • During special enrollments

  • Upon request

  • Upon material modification (during plan year, as defined under ERISA)

Carriers are not required to issue an SBC to all existing enrollees starting September 23, 2012. However, SBCs must be issued for new and renewing individuals and groups for open enrollment periods beginning on or after September 23, 2012, and to any special enrollees on existing plans after that date.

Blue Shield implementation

Blue Shield’s health reform implementation team is working to make sure we are in compliance with the new regulations, including the production of SBCs and other coverage documents.

A distinct SBC form will be developed for every plan offered by Blue Shield. We will provide SBC documentation, including coverage examples, for all product offerings – including self-funded (ASO) plans.

We will be in compliance with the uniform coverage requirements on or before the implementation date. Blue Shield will continue to provide you with updates on further progress in future Health Reform Updates.

Stay in the know

We understand the impact that health reform has on your business and your clients, and we value the opportunity to share with you what Blue Shield is doing.

To help you stay up to date with the latest information, we have provided links to some of the health reform news that will be relevant to you and your business.

Summary of Supreme Court Health Reform Arguments

Officials Ponder how to ensure Health Reform in California 

Thank you for relying on Blue Shield to keep you informed on health reform. Remember to take advantage of the resources, tools, and videos on this site to learn how Blue Shield is implementing the new requirements.



Health Care Reform for Individuals

Looking for information on how health care reform will affect individuals and their families? Learn more.

Our Involvement in Health Care Reform

We're doing all we can to make reform work. Learn how.