by Lexi Garcia | Jun 6, 2024 | Blog
Providing a Summary of Benefits and Coverage (SBC) that is culturally and linguistically appropriate is not just a good practice—it’s a legal requirement for many group health plans. Whether your plan is self-insured or fully insured, it’s essential to understand and comply with these regulations to avoid penalties and ensure your members can access and understand their benefits. In this blog post, we’ll break down what you need to know about furnishing the SBC in languages other than English.
Understanding the Requirement
The SBC must be presented in a “culturally and linguistically appropriate” manner. This requirement is part of a broader effort to ensure that individuals who are literate only in a non-English language can understand their health coverage options. The specific conditions under which this requirement is triggered are based on U.S. Census data.
When Does the Requirement Apply?
The requirement applies if your plan’s SBC is provided to individuals in any county where at least 10% of the population is literate only in the same non-English language. The Department of Health and Human Services (HHS) regularly updates a list of such counties and the languages that apply. As of January 1, 2025, a new list will come into effect, and it’s crucial for plan administrators to stay updated with these changes.
Compliance Steps for Group Health Plans
To comply with the “culturally and linguistically appropriate” requirement, follow these steps:
- Identify Applicable Counties: Check the latest HHS list to see if any counties where your plan members reside meet the 10% threshold for non-English language literacy.
- Provide Interpretive Services: In applicable counties, offer interpretive services in the relevant languages. This includes answering questions and providing assistance in the non-English language.
- Include a One-Sentence Statement: On the SBC, include a one-sentence statement in the applicable non-English languages. This statement should clearly indicate how to access language services. It must be placed on the same page as the “Your Rights to Continue Coverage” and “Your Grievance and Appeals Rights” sections.
- Offer Written Translations: Upon request, provide a written translation of the SBC in the applicable non-English language. The agencies have provided an SBC template that includes this one-sentence statement in all required languages for plan years beginning before 2025.
- Stay Updated: Keep an eye on updates from the HHS, DOL, and IRS regarding additional translations and template updates. These resources will assist in maintaining compliance with the latest requirements.
Voluntary Compliance
Even if your plan does not operate in a county meeting the 10% threshold, you may choose to include the one-sentence statement in any non-English language. If you opt for this, ensure you are prepared to provide the necessary language services.
Differentiating SBC Requirements from ERISA
It’s important to note that the requirements for SBCs differ from ERISA’s rules on language assistance for Summary Plan Descriptions (SPDs) and Summary of Material Modifications (SMMs). Ensure you are familiar with both sets of regulations to avoid confusion and non-compliance.
Meeting the requirement for a culturally and linguistically appropriate SBC is vital for compliance and member satisfaction. By following the steps outlined above, your self-insured group health plan can ensure that all members understand their coverage options, regardless of their primary language. Stay informed, be proactive, and provide the necessary language services to comply with federal regulations and support your diverse member base.
Source: Thomson Reuters
by Lexi Garcia | Mar 9, 2023 | Blog
HHS has proposed regulations that would adopt a set of standards for the electronic exchange of clinical and administrative data to support prior authorizations and health care claims adjudication. As background, HIPAA requires that covered entities (and their business associates) comply with rules designed to standardize the format and content of specified electronic transactions. Specifically, the proposed regulations would adopt standards for “health care attachments” transactions that would support both health care claims and prior authorization transactions, along with a standard for electronic signatures. Regulations proposed in September 2005 would have adopted certain standards for health care attachments but were never finalized.
Explaining that the prior regulations were not finalized due to comments about the standards’ “lack of technical maturity and stakeholders’ lack of readiness to implement electronic capture of clinical data,” the preamble to the new proposed regulations notes that despite the subsequent widespread deployment of electronic health records and greater industry experience with the HIPAA standards, transmitting health care attachments is still primarily a manual process. The preamble provides detailed information about the organizations responsible for developing and maintaining the transactions standards and advises that the timing for implementation is right because the industry consensus-based standards are now mature, and covered entities are ready to implement them. The regulations do not propose to adopt attachments standards for all health care transaction business needs. Instead, the approach is for covered entities to gain experience with several standard electronic attachment types so that technical and business issues can be identified to inform potential future rulemaking for other electronic attachments standards.
Source: Thomson Reuters
by Lexi Garcia | Feb 21, 2023 | Blog
Everyone in the employee benefits field uses acronyms like COBRA, FSA, and CDHC. What do these and other employee benefit acronyms stand for?
Here’s an explanatory list of common employee benefit acronyms used:
ACA – Patient Protection and Affordable Care Act
AHP – Association Health Plan
ASG – Affiliated Service Group
ASO – Administrative-Services-Only
ATIN – Adoption Taxpayer Identification Number
BA – Business Associate
CDHC – Consumer-Driven Health Care
CE – Covered Entity
COB – Coordination of Benefits
COBRA – Consolidated Omnibus Budget Reconciliation Act
COLA – Cost-of-Living Adjustment
CONUS – Continental United States
DCAP – Dependent Care Assistance Program
DOL – Department of Labor
EIN – Employer Identification Number
EAP – Employee Assistance Plan
EBHRA – Expected Benefit HRA
EBSA – Employee Benefits Security Administration
EEOC – Equal Employment Opportunity Commission
EFAST2 – ERISA Filing Acceptance System II
EOB – Explanation of Benefits
EOI – Evidence of Insurability
ePHI – Electronic Protected Health Information
ERISA – Employee Retirement Income Security Act
FICA – Federal Insurance Contributions Act
FLSA – Federal Labor Standards Act
FMLA – Family and Medical Leave Act
FSA – Flexible Spending Amount
FUTA – Federal Employment Tax Act
GHP – Group Health Plan
HCE – Highly Compensated Employee
HCP – Highly Compensated Participants
HDHC – High Deductible Health Coverage
HDHP – High Deductible Health Plan
Health FSA – Health Flexible Spending Arrangement
HHS – Department of Health and Human Services
HIPPA – Health Information Technology for Economic and Clinical Health Act
HMO – Health Maintenance Organization
HRA – Health Reimbursement Arrangement
HSA – Health Savings Account
ICHRA – Individual Coverage HRA
IIAS – Inventory Information Approval System
MCC – Merchant Category Code
PBM – Pharmacy Benefit Manager
PCOR Fees – Fees for Patient-Centered Outcomes Research
PEO – Professional Employer Organization
POP – Premium-Only Plan
PPO Plan – Preferred Provider Organization Plan
QB – Qualified Beneficiary
QE – Qualifying Event
QMCSO – Qualified Medical Child Support Order
QSEHRA – Qualified Small Employer Health Reimbursement Arrangement
R&C – Reasonable and Customary
RRE – Responsible Reporting Identity
SBC – Summary of Benefits and Coverage
SMM – Summary of Material Modification
SPD – Summary Plan Description
TPA – Third Party Administrator
UCR Rate – Usual, Customary, and Reasonable Rate
VEBA – Voluntary Employees’ Beneficiary Association
by Lexi Garcia | Feb 15, 2023 | Blog
The Internal Revenue Service, Department of Labor, and U.S. Health and Human Services Department have issued proposed regulations that would provide an additional method for individuals to obtain no-cost contraceptive services if their health plan or insurer does not provide such services due to a religious exemption. Under final regulations issued in 2018, qualifying religious employers and other entities with sincerely held religious beliefs or moral convictions are exempt from the Affordable Care Act’s contraceptive coverage mandate, which generally requires coverage of contraceptive services without cost-sharing. Exempt entities may voluntarily engage in an accommodation process that allows plan participants to receive contraceptive services directly from a TPA or insurer without the employer’s involvement. In an FAQ issued in 2021, the agencies announced they were considering changes to the 2018 regulations “in light of recent litigation”. Here are highlights of the proposal:
- Individual Contraceptive Arrangement: Leaving in place the existing religious exemptions and accommodations, the agencies have proposed to add a new “individual contraceptive arrangement” through which individuals enrolled in plans or coverage sponsored or arranged by entities with religious objections could access no-cost contraceptive services without the involvement of their employer, group health plan, plan sponsor, or insurer. A provider or facility that furnishes contraceptive services in accordance with the individual contraceptive arrangement would be reimbursed through an arrangement with an Exchange insurer, which would request an Exchange user fee adjustment to cover the costs.
- Moral Exemption Rescinded: The proposed regulations would revoke the 2018 regulations’ moral exemption and accommodation. The agencies explain that “there have not been a large number of entities that have expressed a desire for an exemption based on a non-religious moral objection” and that there is no legal obligation (including under the Religious Freedom Restoration Act) to provide such an exemption.
Source: Thomson Reuters
