What Employers Need to Know About the Health Reform Rules for Summaries of Benefits and Coverage April 10, 2012 Presented by: Jeffrey R. Capwell James P. McElligott, Jr. Felicia L. Mitchell www.mcguirewoods.com
Summaries of Benefits and Coverage ( SBCs ) Some of the issues we will cover today: Who must comply with the SBC rules and when do they take effect? What rights does an employer have to receive an SBC from an insurer who provides group health plan coverage? When must employees receive the SBC? When must employees be notified about changes to the group health plan? What are the formatting and content requirements of the SBC? What methods can be used to deliver the SBC? How does the SBC relate to other plan disclosures? How do the decisions in recent cases impact an employer s liability for misstatements in SBC disclosures? What are the penalties for noncompliance? How will the Supreme Court s decision on the constitutionality of the Patient Protection and Affordable Care Act ( PPACA ) impact the SBC Rules? McGuireWoods LLP 2
Statutory Authority and SBC Regulations PPACA added 2715 to the Public Health Service Act ( PHS ), under which HHS, DOL and IRS develop standards for accurate SBCs and definitions of terms used in health insurance coverage, in consultation with National Association of Insurance Commissioners. PHS 2715 is incorporated by reference into ERISA 715 and IRC 9815. PHS 2792, ERISA 734 and IRC 9833 provide further rulemaking authority to the agencies responsible for such laws Virtually identical regulations for SBCs are found at 29 CFR 2590.715-2715, et seq. (DOL), 26 CFR 54.9815-2715, et seq. (IRS), and 45 CFR 147.200, et seq. (HHS) On March 20, 2012, DOL, IRS and HHS issued Frequently Asked Questions, ( FAQs ) which provide further guidance. See links at end of the presentation. McGuireWoods LLP 3
Who is required to provide an SBC? Applies to: Self-insured and fully-insured group health plans Health insurance issuers in the individual market Including: Grandfathered plans Health reimbursement arrangements (HRAs); may be covered in a combined SBC if HRA is coordinated with another major medical plan Does not apply to: Excepted benefits under HIPAA Non-integral dental and vision coverage Exempt health FSAs Certain specified disease and hospital indemnity insurance Health savings accounts (HSAs) Stand-alone retiree health plans McGuireWoods LLP 4
Who is required to provide an SBC? Responsibility for compliance depends on the nature of the plan: Self-insured group health plans = plan (including the plan administrator) is responsible Fully insured group health plans = both the insurer and the plan are jointly responsible Compliance by insurer or by plan is deemed to be compliance by the other Delegation of SBC responsibility The preamble to the regulations state that SBCs will ordinarily be drafted by insurers and third party administrators ( TPAs ). FAQs state that plans and insurers may contract with another party to complete the SBC, provide information required in the SBC or deliver the SBC Plan or insurer will not be liable for enforcement if: Binding contractual arrangement with the third-party provider They monitor third-party s performance They take action in the event of a violation of SBC rules McGuireWoods LLP 5
When do the SBC rules take effect? Rule 1 = the first day of the first open enrollment beginning on or after 9/23/2012 For those enrolling during open enrollment Rule 2 = the first day of the first plan year beginning on or after 9/23/2012 for persons who enroll other than through open enrollment Newly eligible persons HIPPA special enrollees Planning considerations Acceleration of enrollment period? Practical considerations McGuireWoods LLP 6
Who must be provided the SBC? Participants and beneficiaries have a right to receive the SBC Persons with colorable claim to benefits? See Firestone v. Bruch, 489 U.S. 101, 117-18 (1989). Plans may send a single SBC to both A single SBC can be provided to the participants and beneficiaries at participant s address, provided beneficiaries are not known to reside at a different address Examples: Covered employees and their covered dependents Covered former employees and their dependents (i.e., COBRA participants) Any individual eligible to enroll (i.e., new hires and COBRA qualified beneficiaries) Self-employed individuals and their covered dependents (i.e., independent contractors or partners) Health insurance issuer must provide an SBC (or summary information about coverage) to a group health plan or plan sponsor upon request within 7 business days. McGuireWoods LLP 7
When must SBCs be provided to participants and beneficiaries? At enrollment (i.e., initial enrollment) - with any written enrollment application materials the plan provides If no such materials are provided, then no later than the first date the participant is eligible to enroll himself or any beneficiary in coverage If there are changes to the SBC - no later than the first day of coverage HIPAA special enrollees - no later than 90 days following enrollment Coordinated with timing requirement for SPD delivery Early delivery required upon enrollee s request (see next slide) McGuireWoods LLP 8
When must SBCs be provided to participants and beneficiaries? Upon renewal (i.e., annual enrollment) - if applicable, only for those benefit options in which the participant or beneficiary is enrolled, by either the date the written renewal application materials are distributed to the plan sponsor or, in the case of automatic renewal, no later than 30 days prior to the first day of the new plan year A participant or beneficiary can also request an SBC during renewal for an option in which they are not enrolled. Automatic renewal no requirement to renew and no opportunity to change coverage Upon request no later than 7 business days McGuireWoods LLP 9
When must the SBC be provided if plan coverage is materially modified? Current ERISA rules require notice after plan changes are made 60 days after a material reduction in benefits 210 days after adoption of any other amendment SBC rules require advance notice of material modifications in certain cases Material modification to plan that affects SBC content Modification is not reflected in the most recent SBC, and Modification occurs other than in connection with renewal (new enrollment period) McGuireWoods LLP 10
When must the SBC be provided if plan coverage is materially modified? What is a material modification? Any change to the coverage that independently or in conjunction with other contemporaneous changes would be considered by the average plan participant to be an important change Including changes that reduce or enhance benefits or services, increase or decrease premiums or cost-sharing, or impose new referral requirements Examples Elimination or addition of covered procedures Increase in cost-sharing NOT changes in regulatory requirements (unless the regulators indicate otherwise) McGuireWoods LLP 11
When must the SBC be provided if plan coverage is materially modified? Timing of depends upon effective date of the material modification If a material modification is effective as of the first day of the a plan year, SBC to be provided in connection with the open enrollment preceding the effective date must reflect the modification If a material modification is effective during the plan year, notice of the material modification (or updated SBC) must be distributed at least 60 days before the change takes effect Notice must be provided to all enrollees Recommended approach all who received an SBC Format Either an updated SBC or another format delivered in paper or by electronic format McGuireWoods LLP 12
How many SBCs must be prepared and provided? A separate SBC must be provided for each benefit package offered under the plan and for which the participant is eligible Benefit package = any coverage arrangement with a difference in benefits or cost sharing PPOs, HMOs, standalone HRAs, indemnity options are benefit packages Coverage tiers (e.g., employee only, employee +1, or family coverage are NOT benefit packages Special case for benefit packages that provide different levels of costsharing: If a participant is able to select levels of deductible, copayments and coinsurance for a particular benefit package, one SBC can be provided and can combine information for different cost-sharing selections The appearance must be understandable DOL suggest presenting the information in the form of options and examples should clearly not assumptions used Example: PPO that provides for a both a high and low deductible option Insurers must provide SBCs or summaries to employers upon request even if employers are only shopping for coverage. McGuireWoods LLP 13
What information must be included in an SBC? Uniform definitions Cross references to SPDs are NOT permitted to substitute content requirements But may include cross references to address items not required to be addressed in the SBC, such as plan eligibility A description of the plan s coverage for each category of benefits, including exceptions, reductions and limitations The plan s cost-sharing provisions, such as deductibles, co-pays and coinsurance Information about renewability and continuation of coverage Hypothetical coverage examples selected by HHS to illustrate the benefits that would be provided for certain common benefits scenarios (these examples are included in the final regulations) For coverage beginning on or after January 1, 2014, a statement as to whether the plan provides minimum essential coverage and whether the plan pays at least 60% of the total cost of benefit McGuireWoods LLP 14
What information must be included in an SBC? An internet address (or similar) for obtaining a list of the network providers An internet address where an individual may find more information about the prescription drug coverage under the group health plan or health insurance coverage An internet address where an individual may review and obtain the uniform glossary A disclosure that paper copies of the uniform glossary are available, and a contact phone number for obtaining a paper copy of the uniform glossary A statement that the SBC is only a summary, and that the plan document, insurance policy, contract or certificate of insurance should be consulted for more information about the coverage provided under the plan Contact information for questions or for obtaining a copy of the plan document or the insurance policy, contract or certificate of insurance McGuireWoods LLP 15
What information is optional to include in an SBC? Add-ons to major medical coverage that can affect cost sharing and other information can be combined in the SBC provided the appearance of the SBC remains understandable Examples: Health FSAs HRAs (that are not standalone) HSAs Wellness programs The effects of the add-ons can be noted in the spaces in the SBC for deductibles, copayments, coinsurance and benefits otherwise not covered by major medical coverage Premium information Statement about the grandfathered status of the plan Barcodes and control numbers Generic names for benefit package options (i.e., standard option, high option) Plan s eligibility requirements McGuireWoods LLP 16
What are the format requirements for an SBC? Cross references to SPDs are NOT permitted to substitute content requirements SBC Uniform format based on template and instructions (i.e., 12 pt font or larger, font type) with some flexibility if terms cannot reasonably be described in manner consistent with the template instructions No longer than four double-sided pages (i.e., 8 pages of content) Can be provided as a stand-alone document or included with a summary plan description or other participant disclosure document Terminology must be understandable by average enrollee Minor adjustments to column and row sizes are permitted, but deletion of columns or rows is NOT Uniform glossary Intended to facilitate understanding and comparison of terms and extent of coverage and benefits Cannot be modified Must be provided within 7 business days of request McGuireWoods LLP 17
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What other requirements apply to an SBC? Paper or electronic format is permitted Electronic disclosure by ERISA group health plan plan administrator must meet DOL electronic disclosure rules to participants and beneficiaries More liberal electronic disclosure standards apply to persons eligible but not yet enrolled Culturally and linguistically appropriate language Follow rules for notices with respect to internal claims and appeals procedures If SBC is sent to a county where 10% or more of population is literate only in a non-english language: SBC must include a prominently displayed statement (in the non-english language) of the availability (including how to access) of language assistance services Sample language is available. Plan must provide oral language services in the non-english language Provide notices in the non-english language if requested McGuireWoods LLP 26
What are the rules regarding electronic delivery of SBCs? Rule 1 = Delivery to participants and beneficiaries enrolled in group health plan DOL safe harbor: Active employees with ability to effectively access electronic documents at any location where performing job duties and access to the employer s electronic information system as an integral part of job duties Affirmative consent required for all others (e.g., non-safe harbor employees, retirees, COBRA beneficiaries, and spouses and dependents) Rule 2 = Delivery to participants and beneficiaries eligible for but not enrolled Electronic delivery permitted under a more streamlined process Format must be readily accessible and a paper copy must be provided free of charge upon request Internet posting is permitted, provided participant and beneficiary is timely advised of the posting by paper postcard or email Must have notice that the documents are available, the Internet address, and notify that the documents are available in paper form upon request. Sample postcard is available. Insurers may provide the SBC in paper form or electronically (such as email transmittal or an Internet posting on the issuer s website) McGuireWoods LLP 27
What are the penalties for noncompliance? Violations of SBC Rule Participant or beneficiary who does not receive the SBC Defective SBCs regarding content or form Penalties Civil penalty of up to $100 per day per affected individual under ERISA 502(c) (plan administrator) excise tax of $100 per day per affected individual under Code 4980D. Fines of up to $1,000 per affected individual for willful violations of SBC rule. (plan administrator/plan sponsor) PHS 2715(f), incorporated into ERISA 715. May only be only imposed for content violation and not form Self-reported excise tax on IRS Form 8928 DOL will issue future regulations on procedures for assessing the $1000 fine under PHS 2715. McGuireWoods LLP 28
What is the agencies current approach to enforcement? For the first year of applicability To work with employers, insurers, states, providers and other stakeholders to help them to come into compliance with new law and work with families and individuals help them understand and benefit from the law Compliance assistance is high priority No penalties will be imposed on plans and insurers that are working diligently and in good faith to comply with the SBC rules However, participants can sue plan administrator directly for civil money penalties of up to $100/day under ERISA 502(c). McGuireWoods LLP 29
How do the decisions in cases (like Amara) impact an employer s liability for misstatements? CIGNA Corp. v. Amara, 131 S.Ct. 1866 (2011), ruled that plan document, not SPD, controls entitlement to ERISA benefits, but ERISA 502(a)(3) permits a participant to sue for other appropriate equitable relief, including reformation of the plan, estoppel, surcharge, and make whole relief for fiduciary misstatements in the SPD. Skinner v. Northrop Grumman Retirement Plan B, No. 10-55161 (9th Cir. Mar. 16, 2012), involved an ambiguity in a pension SPD concerning an annuity equivalent offset used to reduce annual benefit amounts payable to retirees. Court found that no remedy was available because plaintiffs failed to show any fraud or reliance, there was no mistake in the actual plan document, no evidence of harm suffered by plaintiffs, and no benefits gained by the fiduciary. McGuireWoods LLP 30
How will the Supreme Court s review of the Affordable Care Act impact enforcement? Outcome of the constitutional challenge won t be known until June 2012. Likeliest outcomes: Court finds the individual mandate constitutional. Court strikes individual mandate along with guaranteedissue and community rating requirements of PPACA (federal government s position). Might remand to lower courts to determine whether other provisions of PPACA are so closely linked to mandate that they should also be struck. Court strikes individual mandate as unconstitutional and refuses to severe, rendering all of PPACA invalid. SBC requirements seem unlikely to be struck in June 2012 unless Supreme Court invalidates all of PPACA. McGuireWoods LLP 31
What resources are available regarding the SBC rules? Resources DOL website - http://www.dol.gov/ebsa/healthreform/ Final regulations Agency FAQs Culturally and Linguistically Appropriate Services (CLAS) County Data HHS website - http://cciio.cms.gov/resources/other/index.html#sbcug Sample completed SBC Instructions for completing SBC Coverage examples calculation guides and narratives McGuireWoods LLP 32
Questions? www.mcguirewoods.com 2012 McGuireWoods LLP McGuireWoods LLP 33
Jeffrey R. Capwell Jeffrey R. Capwell, a partner in the Charlotte office of McGuireWoods LLP, advises employers, plan administrators and other fiduciaries on a wide range of employee benefits matters. This work includes the design and administration of retirement, health and welfare benefit plans, executive compensation and benefit programs and the negotiation of arrangements with plan service providers. He regularly represents clients before federal regulators, including the IRS and the U.S. Department of Labor. Mr. Capwell is the President of the Southern Employee Benefits Conference and is a frequent lecturer on employee benefits and executive compensation topics. He is a cum laude graduate of Dartmouth College and received his law degree, magna cum laude, from Syracuse University College of Law, where he was Editor-in-Chief of the Syracuse Law Review. McGuireWoods LLP 34
James P. McElligott, Jr. Mr. McElligott, a partner in the Richmond, Virginia office of McGuireWoods LLP, handles employee benefits, executive compensation, and labor relations matters for employers and fiduciaries, and has an active litigation and arbitration practice. He is a Fellow of the College of Labor and Employment Attorneys, and is listed in Chambers USA, Best Lawyers in America, and SuperLawyers under both Employee Benefits and Labor and Employment. He is a member of the Employee Benefits Committees of the ABA Sections of Taxation and Labor and Employment Law (co-chair of the Benefits Claims Subcommittee), a member of the US Chamber of Commerce Employee Benefits Committee, former President of the Federal Bar Association, Richmond Chapter, and former president of the Central Virginia Employee Benefits Council. Mr. McElligott is a Phi Beta Kappa graduate of the University of Illinois and received his law degree, cum laude, from Harvard Law School, where he served as Note Editor on the Harvard Journal on Legislation. McGuireWoods LLP 35
Felicia L. Mitchell Felicia L. Mitchell, is an associate in the Charlotte office of McGuireWoods LLP, and advises employers, fiduciaries and plan administrators on employee benefit matters regarding health and welfare plans and retirement and deferred compensation arrangements. She received a B.S. in Accounting, summa cum laude, from Hampton University and a J.D., cum laude, from Georgetown University Law Center. McGuireWoods LLP 36