As indicated in recent agency FAQs regarding the summary of benefits and coverage (SBC) requirement under health care reform, the Department of Health and Human Services (HHS) has made available a model coverage examples calculator, and related instructions and algorithm, to assist plans and insurers in preparing the required coverage examples for the SBC. (The coverage examples component of the SBC is intended to estimate what proportion of expenses under an illustrative benefits scenario might be covered by the plan, to allow a covered individual to make a comparison of his or her share of the costs under different plan options.)
The model calculator is intended as a transitional tool for plans and insurers to use as a safe harbor to complete the coverage examples in a streamlined fashion for the first year of applicability. According to HHS, although this approach will be “less accurate,” it will give plans and insurers “time to develop accurate methods to populate the coverage examples treatment tables” in the SBC template. (More comprehensive coverage examples based on information specific to each benefit package are required no later than Jan. 1, 2014.)
The instructions note that use of the model calculator requires information about the plan’s cost-sharing, deductibles, and coverage limits. They also set forth the assumptions made by the calculator, and walk users through the process of using the tool. The algorithm explains the logic used in the model; HHS indicates that it may help plans and insurers in developing their own calculators. Agency officials have also informally indicated that plans and insurers are not required to use the model calculator, and that it may be modified to more accurately reflect plan provisions and still fall within the safe harbor, so long as the modifications are not likely to result in less accuracy.
SBCs must be provided beginning with 1) the first open enrollment period that begins on or after Sep. 23, 2012, (for those enrolling or re-enrolling in group health plan coverage through open enrollment); and 2) the first plan year that begins on or after that date (for enrollments occurring outside of open enrollment). The safe harbor afforded by the model calculator provides some relief for plans and insurers as they work to develop their own methodologies for producing more accurate coverage examples.
Model coverage examples calculator is available at http://cciio.cms.gov/resources/other/index.html#sbcug.
Instruction for use of the calculator is available at http://cciio.cms.gov/resources/files/sbc-cover-ex-calc-instructions.pdf.
