PacificSource FAQ: Summary of Benefits and Coverage (SBC)

Transcription

1 PacificSurce FAQ: Summary f Benefits and Cverage (SBC) Abut this Dcument This FAQ is an verview f hw PacificSurce will administer the summary f benefits and cverage requirements utlined in the Affrdable Care Act (ACA). Respnses t these questins are based n PacificSurce s interpretatin f ACA and federal guidance. As we receive additinal clarificatins r changes t the requirements frm HHS r the states in ur service areas, we will update this dcument. Recent updates t this dcument are highlighted. If an emplyer needs legal guidance n their requirements, they shuld cntact their attrney r CPA. The infrmatin in this FAQ is nt intended t be legal advice. Questins are gruped int the fllwing tpics. T jump t that area f the FAQ, click n a link belw. Yu can als press Ctrl F r Cmd F t search this dcument by key wrd. Backgrund Definitins General Infrmatin Cntent f the SBC Qutes (fr Agents) Renewal Ntices Distributin Backgrund The ACA requires all grup health benefit plans and insurers ffering grup r individual health benefit plans t prvide a written summary f benefits and cverage (SBC) fr each benefit package t plicyhlders, subscribers, dependents, and applicants. The riginal prvisins stated that the SBC was t be effective March 23, HHS, DOL, and the Treasury published final rules n the SBC n February 14, 2012 and changed the effective date t September 23, 2012 t allw plans and insurance carriers time t develp and cde their systems. They als develped a standardized SBC dcument and a unifrm glssary dcument that all grup health benefit plans and insurers are required t use. Definitins What is the summary f benefits and cverage (SBC) dcument? The SBC dcument is intended t prvide cnsumers with a cncise dcument explaining, in plain language, simple and cnsistent infrmatin abut health plan benefits and cverage. It summarizes the key features f the plan, such as the cvered benefits, cst-sharing prvisins, and cverage limitatins and exceptins. The cntent and frmatting requirements are strict and used industry-wide thrughut the United States t allw easy cmparisn f cverage ptins between carriers. What is the unifrm cverage dcument? It is the name that the ACA riginally called the summary f benefits and cverage. They are the same dcument. Refrm FAQs - SBC (published August 24, 2012; last updated January 10, 2013) Page 1 f 10

2 What is the unifrm glssary? The unifrm glssary includes many cmmnly used definitins f health cverage and medical terminlgy, but isn't a full list. These glssary terms and definitins are intended t be educatinal and may be different frm the terms and definitins fr a plan. Sme f these terms als might nt have exactly the same meaning when used in a plicy r plan, and in any such case, the plicy r plan gverns. The glssary may nt be mdified by plans r issuers and is t be prvided in cnnectin with the SBC. What is a material mdificatin? Material mdificatin refers t bth increases and decreases in benefits. Examples f benefit increases include cverage f previusly excluded benefits r reduced cst-sharing. A material mdificatin culd als be a material reductin in cvered services r benefits as described in the existing Department f Labr guidance at 29 CFR b-3(d)(3) and include increases in premium, increase in ut-f-pcket amunts, adverse change in an HMO service area and any new, mre stringent requirements fr receipt f benefits (such as new pre-certificatin requirements).the ACA directs that a grup health plan r insurance issuers (grup r individual) prvide ntice f a material mdificatin f cverage (as defined under ERISA sectin 102), at least 60 days in advance, if any f the changes in cverage are nt reflected in the mst recently prvided SBC. What is a HIPAA special enrllee? A HIPAA special enrllee is a late enrllee wh has special enrllment rights. Basically, it smene with a qualifying event as determined by state regulatins. Qualifying events include marriage, birth r adptin f a child, invluntary lss f ther cverage. General Infrmatin What is the purpse f the SBC? The intent f the SBC is t help cnsumers better understand their healthcare ptins. The SBC prvides cnsumers with a standardized benefit exhibit t help them cmpare the benefits f varius health insurance prducts. What types f PacificSurce plicies are required t use the SBC? SBCs are required fr cmmercial grup (bth fully insured and self-insured), individual medical insurance plicies, and health reimbursement arrangements (HRAs). The SBC is nt required fr Medicare Advantage, Medicaid, dental-nly plicies (ther than pediatric dental), r ur healthcare FSAs (flexible spending accunts). Nte that while dental-nly cverage is nt subject t SBC requirements, we have re-frmatted the benefit summary in ur dental nly handbks t be cnsistent with the SBC by listing the member s cst-share instead f the PacificSurce benefit level. Des it matter whether my grup is fully-insured r self-funded (ASO)? SBCs are required fr bth fully-insured and self-insured plicies. The health insurance carrier is respnsible fr creating the SBC n fully-insured plicies. The emplyer grup is respnsible fr creating the SBC n self-funded plicies. Hwever, as a curtesy, PacificSurce will prvide self-funded grups with an SBC if their plan design allws fr it t be prduced thrugh ur dcument data-base withut manual interventin. Will ne versin f the SBC wrk fr grup and individual business in all states? HHS nly created ne versin f the SBC template, but issued separate instructins fr the grup and individual plicies. In additin, the member cst-share and limits vary by plan design and prduct. HHS requires that the same SBC be used natin-wide. In general, the member cst-share and limits vary by plan design and prduct. When must plans and insurers begin using the SBC and unifrm glssary? Plans and insurers must use the SBC and glssary beginning September 23, 2012, as fllws: Refrm FAQs - SBC (published August 24, 2012; last updated January 10, 2013) Page 2 f 10

3 Fr grup members wh enrll r re-enrll thrugh an pen enrllment perid (including re-enrllees and late enrllees), the effective date is n the first day f the first pen enrllment perid beginning September 23, (It is the emplyer grup s respnsibility t ntify their insurer f their final benefit plan package selectin and f their pen enrllment perid in advance t allw the insurer time t create the SBC prir t the pen enrllment perid.) Fr grup members wh enrll in cverage ther than thrugh pen enrllment (including individuals wh are newly eligible fr cverage and special enrllees), the effective date is the first day f the first plan year that begins n September 23, Fr the individual market (participants, beneficiaries, and applicants), the effective date is September 23, What are the general SBC standards? The standards are designed t guide the cnstructin f the SBC in the fllwing areas: appearance, language, frm, and cntents. Appearance An SBC must be presented in a unifrm frmat, may nt exceed fur, duble-sided pages in length, and may nt include print smaller than 12-pint fnt. Language An SBC must be presented in a culturally and linguistically apprpriate manner and must utilize terminlgy understandable by the average plan enrllee. Under this standard, plans and issuers are required t disclse the availability f language assistance in nn-english languages. In cunties where at least 10% f the ppulatin is fluent in a language ther than English, the SBC must be available in that nn-english language and the English SBC must cntain a prminent ntice ffering language assistance in that nn-english language. Frm An SBC can be prvided in paper r in electrnic frm. The final rule varies the requirements fr electrnic delivery depending n the market invlved, and in the grup market depending n whether the participant is currently enrlled in cverage r nt. See the Delivery sectin f this FAQ fr mre infrmatin. Cntent At a minimum, ACA requires an SBC t include: unifrm definitins f standard insurance and medical terms; a descriptin f the cverage, including cst sharing; exceptins, reductins, and limitatins n cverage; the cst sharing prvisins; renewability and cntinuatin f cverage prvisins; cverage examples; a statement f whether the plan r cverage prvides minimum essential cverage and a minimum value statement (fr cverage beginning n r after January 1, 2014); a statement that the utline is a summary and that the cverage dcument itself shuld be cnsulted t determine the cntrlling cntractual prvisins; and a cntact number fr asking questins r btaining a cpy f the plan dcument r plicy. The final rule als includes as applicable, cntact infrmatin fr btaining a list f netwrk prviders and infrmatin n prescriptin drug cverage as well as an Internet address and cntact number fr btaining the unifrm glssary, and a disclsure that paper cpies are available. There are mre than ne-hundred input fields in the SBC, which cver mst benefits and limitatins f each health insurance plan. Hwever, members shuld cntinue t als refer t the member handbk r plicy fr mre detailed infrmatin. The SBC des nt include premium r cst f cverage, r benefits insured by ther carriers r third party administratrs. In additin, there is sme flexibility fr plans (fr example tiered netwrks) that d nt fit int the template/instructins. What are the csts yur cmpany may charge t prduce and distribute the SBC? Fully-Insured Grups PacificSurce will create and distribute SBCs based n regulatry requirements. There is n additinal cst t the emplyer grup, unless there are special distributin requests that are utside the regulatry requirements that results in additinal expense. In thse rare cases, the additinal expense wuld be passed n t the emplyer grup. Self-Funded Grups If the grup s SBC can be created using ur autmated dcument prductin system withut manual interventin, there is n charge t the grup fr this service. If we must create it manually, regardless f Refrm FAQs - SBC (published August 24, 2012; last updated January 10, 2013) Page 3 f 10

4 whether it is an SPD r a SBC, the grup will be charged $1,000 per dcument plus printing and distributin csts. There is n charge fr electrnic distributin. Many self-funded grups will elect t create their wn summaries because they cntract with multiple vendrs. In these cases, we are happy t prvide them a sample SBC t help them with language decisins, as well as pst their SBC n InTuch (ur secure nline prtal at PacificSurce.cm) fr their members t access at n additinal charge. What is the penalty fr nncmpliance? A grup health plan (including its administratr), and a health insurance issuer ffering grup r individual health insurance cverage, that willfully fails t prvide required infrmatin will be subject t a fine f nt mre than $1,000 fr each such failure. Each failure t deliver the SBC t an individual cnstitutes a separate ffense under the Act. In the first year, regulatrs have agreed t take a mre accmmdative apprach and nt penalize carriers r emplyers if they are wrking diligently and in gd faith t satisfy the SBC requirement. What is the rle f the agent/brker in regards t the SBC? Yu just need t use SBCs instead f ther frms f summaries when presenting qutes t grups. The SBC shuld be used instead f agent generated spreadsheets r summaries. Please see the Qutes sectin fr mre infrmatin. Cntent f the SBC Is the SBC the fficial cverage descriptin under the grup health plan? N. The SBC is intended as an easy-t-read summary and prvides nly a general verview f benefits. It is nt a cntract. Fr a cmplete descriptin f benefits and terms f cverage, cnsult the applicable PacificSurce handbks, plicy, r SPD. Are we required t have a separate dcument fr every type grup (i.e., individual, individual + family, etc.)? N. The HHS clarified in FAQs it released in March 2012 that "Individual + Family" wuld be acceptable. We will nt create different versins based n family structure, regardless if it is a grup r individual plicy. What types f services will yu include n the SBC under Other practitiner ffice visit? Examples f ther practitiner ffice visits that we will list here include alternative and chirpractic care, as well as services a large emplyer grup may have custmized with a different member cst-share than regular ffice visits. Will yu include preauthrizatin infrmatin n the SBC? Yes. Fr the benefits listed n the SBC, we will briefly nte the medical preauthrizatin requirements in the Limitatins & Exceptins clumn. Please nte that there may be benefits that require preauthrizatin that are nt listed n the SBC. In additin, the preauthrizatin is subject t change, s it is imprtant t reference the preauthrizatin list n ur website at Fr pediatric dental and visin, what infrmatin will be included? Thse rws n the medical SBC will include the benefits frm the Basic Health Plan (BHP) in Oregn, the new PacificSurce preventive dental endrsement, and anything else that may be required by the ACA. Fr prenatal and pstnatal care, what infrmatin will be included? The SBC is meant t cver standard situatins and nt every scenari, s we will list benefits fr a regular pregnancy. We will nt include details n high-risk r emergent pregnancy. Why is maternity included as a scenari when my plan desn t cver maternity benefits? The ACA requires us t list the maternity scenari n the SBC, even if the plan des nt cver maternity (as is the case with sme Idah plans). In additin, certain benefits may be cvered regardless f whether the member has maternity Refrm FAQs - SBC (published August 24, 2012; last updated January 10, 2013) Page 4 f 10

5 cverage. Fr example, if a pregnant member s bstetrician gives her a flu vaccinatin, it wuld still be cvered under the member s preventive care benefits. Fr glasses, what infrmatin will be included? Due t limited space, PacificSurce-prduced SBCs will nly shw the single visin + frames benefit if cvered. What if a large emplyer grup desn t like the way certain infrmatin is wrded n the SBC? Can it be changed? Generally, n. While we have been very flexible n wrding n ur benefit summaries and member handbks in the past fr grups with custm benefits and eligibility, the final rules n the SBC will nt allw fr such flexibility. Much f the language is specifically defined in the final rules. Sme f the language, such as preventive care limits, is intentinally brief t cmply with frmatting requirements. Fr ther language, we must be cnsistent acrss all grups fr the same benefit. The nly variatin allwed is fr specific plan design benefits (such as c-payment amunt r whether a service is cvered r excluded). If my grup has a plan year deductible, can yu change usually, but nt always, January 1st language in the deductible sectin t reflect the mnth their plan year starts. N. Final rules d nt allw carriers t alter the language in that sectin, as it is listed as a nn-editable paragraph. If my grup has an incentive drug plan r variatins, where will that infrmatin be listed? We will nte the c-payment fr the incentive drugs in the limits clumn n the generic rw. If members are allwed t select deductible, c-pays, and c-insurance fr a particular benefit package, are plans and issuers required t prvide a separate SBC fr every pssible cmbinatin that might be selected? N, separate SBCs are nt required in this situatin; hwever, PacificSurce is creating a different SBC fr each cmbinatin as a curtesy t ur grups. D grups with a PacificSurce health plan design and a prescriptin drug plan design thrugh anther carrier need t prvide a cmbined SBC fr medical and pharmacy benefits? Emplyer grups will eventually have t prvide cmbined SBCs. Hwever, federal guidance currently allws emplyers t prvide separate SBCs fr medical and pharmacy plan designs fr this situatin during the first year. If I have ancillary benefits (riders), such as visin r pharmacy, will PacificSurce include that infrmatin n the SBC fr my medical plan design? The answer depends n the type f rider, and n whether PacificSurce is yur carrier fr thse additinal benefits: Please nte that we will cntinue t have ancillary benefit summaries. Even fr the benefits such as pharmacy that are listed n the medical SBC because there is nt enugh detail t eliminate the ther summaries. Additinal Accident: N. There is n sectin n the SBC fr Additinal Accident s it is nt listed. Abrtin Rider: N. There is n sectin n the SBC fr Abrtins s it is nt listed. Alternative Care: Yes. Alternative care is listed in the Office Visit rw regardless f whether it is standard fr the medical plan r if it s a rider. Visin Riders: Yes and N. The If Yur Child Needs Dental r Eye Care sectin (n page 5 f the SBC) lists the eye exam and single eye glasses benefit fr children. The specific visin summary prvides mre details. The Services Yur Plan Des NOT Cver sectin (n page 7) lists visin exam if nt cvered. Refrm FAQs - SBC (published August 24, 2012; last updated January 10, 2013) Page 5 f 10

6 The Other Cvered Services sectin (n page 7) lists visin exam as cvered. This is the nly place that wuld indicate any type f adult visin cverage. N specific benefits are listed. The specific visin summary prvides mre details. Ancillary benefits thrugh a different carrier: N. Since the ther carrier s data is nt set up in ur claims system, ur dcument creatin system is unable t pull it nt the SBC. In additin, PacificSurce cannt cnfirm r be respnsible fr the cntents f ther carrier s benefits. HHS has made a Wrd template available: If an emplyer grup elects t re-type the infrmatin frm their grup-specific PacificSurce prduced SBC t cmbine it with their ther carrier s infrmatin int ne dcument, the fter shuld indicate wh created the SBC. Will the SBC be prvided in an editable frmat r will PacificSurce allw the grup t add infrmatin t the SBC such as infrmatin abut their HRA financial arrangements? The SBCs are in a nn-editable frmat, as they have ur cmpany name n them and we are accuntable fr the cntent we put n them. Our dcument data-base system pulls data int the SBCs frm multiple data fields in ur claims system, and the utput is a PDF dcument. Hwever, the Wrd template nted in the abve questin is in an editable frmat, s the grup culd use the infrmatin n the PDF we create t fill it in, alng with the infrmatin frm any f their ther vendrs. Fr grups that have their HRA thrugh PacificSurce Administratrs, we are lking int the pssibility f integrating that int ur static dcuments fr phase II f the SBC prject. Why d the scenaris n the SBC nt match my actual plan benefits? In the Scenaris sectin f the SBC, yu may see a different deductible r cpay amunt than what is n the plan. This is because gvernment regulatins require that these numbers be runded. Amunts under $100 are runded t the nearest tenth, and amunts greater than $100 will be runded t the nearest hundredth. Fr example, if the deductible is $750 yu will see $800 and if a cpay is $15 yu will see $20. This is why the amunts d nt always add up in the calculatins crrectly. We realize the runding f these numbers may cause cnfusin; hwever, this is a requirement f the ACA and we must cmply with the requirements. Qutes (fr Agents) Hw d I btain an SBC t prvide t my clients with qutes? Carriers are required t make SBCs available fr health qutes requested n r after September 23, We expect t have the SBCs fr ur standard marketed plan designs available n ur website a few weeks prir t that requirement, and will ntify agents as sn as they are psted. Once they are available, the fllwing applies. Grup Plicies We will pst standard SBCs fr each f ur marketed health plan designs n PacificSurce.cm in the same area as ur plan summaries fr yur cnvenience. While they will include sme limited infrmatin n ur mst cmmnly used pharmacy and visin plan designs, mre detailed benefit summaries fr thse ancillary prducts will cntinue t be available in that same area f ur website. Yu can als cntact yur Sales Executive fr a hard cpy if yu d nt have a printer available. Upn request, we will als prvide a cpy in any packet r sales presentatin we participate in. If yur grup chses PacificSurce as their carrier, we will include cpies f their grup-specific SBC in the meeting packets. T d s, hwever, we need t receive their Request fr Grup Insurance frm (master applicatin) and benefit and eligibility details in advance f the meetings. Otherwise, packets will cntain generic SBCs with a nte that they will receive their final SBC when we distribute benefit handbks n InTuch (ur secure nline prtal at PacificSurce.cm). Individual Plicies The qute will autmatically include the SBC fr the specific plan design qute requested. If the individual des nt select a plan design n their applicatin, we will cnsider the applicatin incmplete and will be unable t prvide an SBC r cnsider their applicatin until we receive their plan design selectin. Regulatins require that carriers prvide the SBC upn request and it must be prvided at the time f applicatin (r as sn as practicable fllwing receipt f the applicatin, but n later than seven business days fllwing receipt f applicatin). Refrm FAQs - SBC (published August 24, 2012; last updated January 10, 2013) Page 6 f 10

7 If the individual decides t select PacificSurce, we will distribute an SBC with their plicy fr the plan design they chse and include an electrnic versin n InTuch. On standard medical SBCs fr quting purpses, what pharmacy and visin benefit will be listed? The mst cmmn marketed pharmacy and visin plan in that state will be listed. If at the time f sale the grup selects a different pharmacy r visin benefit, the SBC will be updated with grup-specific benefits. If my client decides t enrll with PacificSurce and they select a standard medical plan design, d they have t select the pharmacy plan design that is n the standard SBCs n yur website? The answer varies based n the type f plicy, as fllws: Grup Plicies If yu select a HSA+Rx plan design, the pharmacy plan listed n the SBC is based n IRS guidelines and cannt be changed (althugh yu can select an HSA plan design that excludes pharmacy cverage). If yu select any ther medical plan design, the standard SBC n ur website lists ur mst cmmn pharmacy plan design fr that state. If yu prefer a different pharmacy plan design r just want the pharmacy discunt prgram, we will replace that n the SBC we persnalize fr yur grup at time f new grup enrllment r renewal. Since the SBC nly cntains limited infrmatin n pharmacy plan designs, there are mre detailed pharmacy benefit summaries n ur website. Individual Plicies The medical and pharmacy plan designs are pre-defined as a package. The pharmacy plan design listed n the SBC is the nly ne available with that medical plan and cannt be remved. Will PacificSurce create custm SBCs at time f qute fr large emplyer grups? N, nt in general. SBCs are generated based n the benefits cded in ur system, and we can t cde the grup s benefits in ur system until we have cnfirmed final benefits and eligibility. The SBC will reflect ur marketed plan designs until benefits have been cnfirmed in writing. If a grup has 500 r mre cvered emplyees and we becme a finalist, we can create a custm SBC manually. Hwever, it will nt be the final SBC as we use actual benefit data in ur system t generate the final versin. Renewal Ntices Fr fully-insured grups, shuld we expect t receive renewals sner? The revised final rules have relaxed sme f the riginal timelines. Fllwing are the timelines yu shuld expect t receive renewals ntices. Small emplyer grups (2 50 emplyees) Our target is 60 days prir t renewal. Large emplyer grups (51 r mre emplyees) Our target remains at 90 days prir t renewal (unless therwise negtiated n a jumb size grup). When d grups need t submit renewal cnfirmatins t PacificSurce? T assist with the SBC creatin and distributin timelines, it is imprtant that grup administratrs and/r their agents submit their final renewal cnfirmatin decisins t carriers at least 30 days prir t their renewal date. T assist with this, PacificSurce distributes renewal ntices t grup administratrs and/r their agents 60 days in advance fr small emplyer grups and 90 days in advance fr large emplyer grups. Will PacificSurce prvide an SBC with renewal ntices? Yes, fr bth grup and individual plicies. Refrm FAQs - SBC (published August 24, 2012; last updated January 10, 2013) Page 7 f 10

8 Distributin When des PacificSurce expect t have SBCs available? PacificSurce will begin lading SBCs fr ur current grups and individual plicyhlders t InTuch, ur secure nline prtal fr members, emplyers, prviders, and agents n September 4, 2012 and will have them all laded by September 23, 2012 based n the benefits and eligibility set-up fr that emplyer grup r plicyhlder as f that date. Wh shuld members cntact t request an SBC? Members currently enrlled with PacificSurce shuld call the custmer service number lcated n their member ID card. Grup emplyees nt currently enrlled with PacificSurce cverage shuld cntact their grup administratr fr SBCs. When will renewing grups begin t receive SBCs? We will begin prviding SBCs t renewing grups n later than September 23, 2012 if their pen enrllment perids start n r after that date. Renewing grups that have pen enrllment perids beginning befre that date will receive renewal materials we currently prvide (althugh we will include the SBC if it is ready). Due t ur system s prcess, we cannt take requests fr early distributin fr a specific grup. When will new hires begin receiving SBCs? The SBC will be included in the applicatin materials fr enrllment. If emplyer des nt distribute materials fr enrllment, then the SBC will be prvided n later than the first date n which the emplyee is eligible t enrll fr cverage. Emplyees nt currently enrlled with PacificSurce will be referred t their plan administratr fr SBCs, as PacificSurce will nt be able t verify their eligibility. What are the general timelines fr SBC availability r distributin? See the fllwing table fr general examples n distributin timelines, starting n r after September 23, SBCs will als be available n InTuch. Emplyer Grup Scenari Upn request Upn cmpleted applicatin received by the carrier At renewal (if renewal autmatic) At renewal (if renewal nt autmatic) Benefit change at renewal Material benefit change ff f renewal New hire Special enrllment SBC Must Be Sent Within 7 business days Within 7 business days At least 30 days prir t renewal At pen enrllment On r befre the first day f cverage 60 days prir t change With the applicatin materials fr enrllment. (If emplyer des nt distribute materials fr enrllment, then the SBC will be prvided n later than the first date n which the emplyee is eligible t enrll fr cverage.) Within 90 days f enrllment Individual Plicy Scenari Individual r family shpping fr cverage SBC changes after applicatin but befre cverage begins SBC Must Be Sent PacificSurce will include it with the qute request if the individual selects a plan design. Within 7 business days Refrm FAQs - SBC (published August 24, 2012; last updated January 10, 2013) Page 8 f 10

9 Upn request Upn cmpleted applicatin At renewal (if renewal autmatic) At renewal (if renewal nt autmatic) Benefit change at renewal Material benefit change ff f renewal Within 7 business days Within 7 business days At least 30 days prir t renewal If renewed thrugh an applicatin frm (paper r electrnic), the SBC will be distributed with the applicatin. On r befre the first day f cverage 60 days prir t change Wh is respnsible fr creating and distributing grup-specific SBCs? Fully-Insured Grups The insurer must create and prvide the SBC t the emplyer grup. Under federal law, the insurer and the emplyer have an bligatin t create and distribute the SBC t members. T prevent duplicatin, the law permits the insurer and fully insured accunt t enter int an agreement abut each party's respnsibilities. PacificSurce will create the SBC as a value-added service and prvide a cpy t the grup, wh can distribute cpies t their cvered members. PacificSurce will als autmatically lad a cpy f the SBC nt ur secure nline prtal (InTuch) fr members, grups, and prviders t access n their wn. Self-Funded Grups The respnsibility t create and distribute the SBC lies with the emplyer, plan spnsr, r plan administratr. Hwever, PacificSurce will create the SBC as a value-added service and prvide a cpy t the selffunded grup if it can be autmated within ur dcument prductin system. In general, if a self-funded grup s SPDs g thrugh ur autmated dcument prductin system, then their SBC can t. The emplyer grup is respnsible fr distributing the SBC t plan participants and beneficiaries. Hwever, if a self-funded grup currently uses ur secure nline prtal (InTuch), PacificSurce will als autmatically lad a cpy f the SBC nt InTuch fr members, grups, agents, and prviders t access n their wn. The final regulatins include an anti-duplicatin rule under which a single SBC may be prvided t a family unless any beneficiaries are knwn t reside at a different address. In that case, an SBC must be sent t the last knwn address f that beneficiary. Will PacificSurce be sending ut the SBC, r can I (the agent) request them? Yu d nt need t request the SBC n behalf f yur client. We will autmatically send them ut with the renewal rates based n current benefits, and enclse a letter ntifying the grup what will change at renewal. Once we receive a renewal cnfirmatin, we will distribute their SBC based n their renewal decisins at the same time that we distribute benefit handbks, and pst it t InTuch. Are plans and carriers required t distribute the unifrm glssary autmatically? The plan r issuer is required t distribute the unifrm glssary via r mail within seven days f request. In additin, we will make the dcument available in the refrm sectin f ur website and include infrmatin in ur billing ntices, newsletters, and member ntices n hw t access it. D the final regulatins allw fr electrnic transmissin f the SBC t participants and beneficiaries? The final rules permit SBCs t be prvided electrnically under a variety f circumstances. PacificSurce will prvide electrnic SBCs in a frmat that allws them t be saved r printed fr future reference ( ed as a PDF and als saved n ur InTuch nline prtal). A hard cpy SBC will als be made available free f charge upn request t ur fullyinsured members and individual plicyhlders. I have an HRA thrugh PacificSurce Administratrs, Inc. (frmerly Manley Services). Will PacificSurce distribute SBCs fr their current plicyhlders? Grup has HRA thrugh PacificSurce Administratrs and medical cverage thrugh PacificSurce Health Plans PacificSurce Administratrs will prvide an SBC fr the HRA plan and PacificSurce Health Plans will prvide an SBC fr the Medical plan separately. We are actively develping a prcess t integrate the HRA plan nt the Medical plan SBC as part f phase II f ur SBC prject, and will ntify Agents and Grup Administratrs when it is available. Refrm FAQs - SBC (published August 24, 2012; last updated January 10, 2013) Page 9 f 10

10 Grup has HRA thrugh PacificSurce Administratrs and medical cverage thrugh a different carrier PacificSurce Administratrs will prvide an SBC fr the HRA plan nly. Will yur cmpany include the SBC with the benefit bklet r SPD? The SBC will replace the summary f benefits n InTuch fr all grup and individual plicyhlders n later than September 23, regardless f when they renew. It will als be attached with the electrnic distributin f handbks and plicies fr fully-insured grups and individuals at renewal. The SBC will nt be included in the bdy f benefit handbks r plicies at this time, but that may change in the future as each state makes that decisin. If a self-funded grup currently uses PacificSurce s standard SPD frmat that is generated thrugh ur autmated dcument system, the SBC will als be attached with the electrnic distributin f that SPD at renewal. Hwever, we are updating the handbk benefit f summaries and cntract schedules t be written in a similar manner as the SBC by indicating member cst-sharing respnsibility (c-payments and c-insurance) instead f benefit levels. My September renewing grups wuld like t get their SBC early. If their handbks are ready prir t September 23rd, can yu distribute the SBCs with them? PacificSurce will begin generating SBCs n September 4, 2012, and will cntinue t generate them daily t ensure they are cmplete by September 23. If yur grup s SBC is finished prir t the distributin f their handbks, we will include the SBC with them. Otherwise, their SBC will be psted in InTuch by September 23, Due t the prgramming and testing requirements, we are unable t mve a specific grup up in the prcess. Can yu accept my benefit and eligibility cnfirmatin verbally fr purpses f creating my grup s SBC? N. PacificSurce cannt create SBCs fr a new grup prir t receiving written cnfirmatin f yur benefits and eligibility as that is required befre we can set up yur grup in ur system, which is necessary befre a grup specific SBC can be created. If yu are selecting a standard plan design, yu can use ne f the SBCs n ur public website, PacificSurce.cm (lcated under Fr Agents > Plan Summaries: What are the guidelines fr assciatins, trusts, MEWAs, and prfessinal emplyer rganizatins? PacificSurce is finalizing ur questins and answers fr these multiple emplyer entities based n recent additinal guidance. Refrm FAQs - SBC (published August 24, 2012; last updated January 10, 2013) Page 10 f 10