CCIIO Develops and Makes Available Summary of Benefits and Coverage Calculation Tool

The Center for Consumer Information and Insurance Oversight (CCIIO) has made available on its website a calculation tool and instructions to help group health plans and health insurance issuers comply with certain summary of benefits and coverage (SBC) requirements under the Affordable Care Act (ACA). The ACA requires these plans and issuers to provide consumers with a SBC that “accurately describes the benefits and coverage under the applicable plan or coverage” to enable enrollees and participants to better compare plan terms and benefits. Final regulations implementing the SBC were issued in February 2012.  Among other mandates, participants and beneficiaries must be provided with coverage examples to show how certain common medical conditions, such as pregnancy and diabetes, are covered under the plan.

To this end, the CCIIO has created the calculation tool for plans and issuers to use as a safe harbor for the first year of applicability. According to the calculator instructions: (pdf)

because this approach will be less accurate, it is being allowed as a transitional tool for the first year of applicability. This tool is intended to provide plans and issuers with time to develop accurate methods to populate the coverage examples treatment tables in the summary of benefits and coverage (SBC) template. 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 discrete number of elements about the benefit package. Calculator inputs generally are expected to coincide with the data fields used to populate the front portion of the SBC template.

To use the calculators, plans and issuers will need information on the plan’s cost sharing, deductibles, and coverage limits for various benefit categories.

Photo credit: Bartek Szewczyk

Information contained in this publication is intended for informational purposes only and does not constitute legal advice or opinion, nor is it a substitute for the professional judgment of an attorney.