Under the Patient Protection and Affordable Care Act (ACA), starting September 23, 2012, group health plans and health issuers are required to meet the reporting and disclosure requirements of Public Health Service Act (PHSA) Sec. 2715, namely, to provide a summary of benefits and coverage (SBC) that accurately describes the benefits and coverage under the applicable plan or coverage. The SBC is required to include 12 content elements, and one of these elements is coverage examples that illustrate benefits provided under the plan or coverage for common benefits scenarios (such as pregnancy and chronic medical conditions).
On June 5, the Center for Consumer Information and Insurance Oversight (CCIIO) provided health insurance plans and issuers with a coverage example calculator on its website. The calculator is for plans and issuers to use as a safe harbor for the first year of applicability to complete the coverage examples in a streamlined fashion. This tool is intended to provide plans and issuers with time to develop accurate methods to populate the coverage examples treatment tables in the SBC template. However, the CCIIO noted that because this approach will be less accurate, it is being allowed as a transitional tool for the first year of applicability. Plans and issuers will be required to provide comprehensive coverage examples that are based on the coverage information specific to the benefit package no later than January 1, 2014.
The calculator allows plans and issuers to input a number of elements about the benefit package, such as information on the plan's cost-sharing, deductibles, and coverage limits for several benefit categories. Calculator inputs generally are expected to coincide with the data fields used to populate the front portion of the SBC template.