Federal Register / Vol. 76, No. 162 / Monday, August 22, 2011 / Proposed Rules 52475 

that is consistent with the rules of 

paragraph (a)(4) of this section. 

(c) Uniform glossary—(1) In general. 

A group health plan, and a health 

insurance issuer offering group health 

insurance coverage, must make 

available to participants and 

beneficiaries, and a health insurance 

issuer offering individual health 

insurance coverage must make available 

to applicants, policyholders, and 

covered dependents, the uniform 

glossary described in paragraph (c)(2) of 

this section in accordance with the 

appearance and format requirements of 

paragraphs (c)(3) and (c)(4) of this 

section. 

(2) Health-coverage-related terms and 

medical terms. The uniform glossary 

must provide uniform definitions, 

specified by the Secretary in guidance, 

for the following health-coverage-related 

terms and medical terms: 

(i) Allowed amount, appeal, balance 

billing, co-insurance, complications of 

pregnancy, co-payment, deductible, 

durable medical equipment, emergency 

medical condition, emergency medical 

transportation, emergency room care, 

emergency services, excluded services, 

grievance, habilitation services, health 

insurance, home health care, hospice 

services, hospitalization, hospital 

outpatient care, in-network coinsurance, in-network co-payment, 

medically necessary, network, nonpreferred provider, out-of-network coinsurance, out-of-network co-payment, 

out-of-pocket limit, physician services, 

plan, preauthorization, preferred 

provider, premium, prescription drug 

coverage, prescription drugs, primary 

care physician, primary care provider, 

provider, reconstructive surgery, 

rehabilitation services, skilled nursing 

care, specialist, usual customary and 

reasonable (UCR), and urgent care; and 

(ii) Such other terms as the Secretary 

determines are important to define so 

that individuals and employers may 

compare and understand the terms of 

coverage and medical benefits 

(including any exceptions to those 

benefits), as specified in guidance. 

(3) Appearance. A group health plan, 

and a health insurance issuer, must 

provide the uniform glossary with the 

appearance authorized in guidance, 

ensuring that the uniform glossary is 

presented in a uniform format and 

utilizes terminology understandable by 

the average plan enrollee (or, in the case 

of individual market coverage, an 

average individual covered under a 

health insurance policy). 

(4) Form and manner. A plan or issuer 

must make the uniform glossary 

described in this paragraph (c) available 

upon request, in either paper or 

electronic form (as requested), within 

seven days of the request. (Under the 

rules of paragraph (a) of this section, the 

form authorized in guidance for the SBC 

will disclose to participants, 

beneficiaries, and individuals covered 

under an individual policy their rights 

to request a copy of the uniform 

glossary.) 

(d) Preemption. For purposes of this 

section, the provisions of section 2724 

of the PHS Act continue to apply with 

respect to preemption of State law. In 

addition, with respect to the standards 

for providing an SBC required under 

paragraph (a) of this section, State laws 

that require a health insurance issuer to 

provide an SBC that supplies less 

information than required under 

paragraph (a) of this section are 

preempted. 

(e) Failure to provide. A health 

insurance issuer or a non-Federal 

governmental health plan that willfully 

fails to provide information required 

under this section is subject to a fine of 

not more than $1,000 for each such 

failure. A failure with respect to each 

covered individual constitutes a 

separate offense for purposes of this 

paragraph (e). HHS will enforce these 

provisions in a manner consistent with 

45 CFR 150.101 through 150.465. 

(f) Applicability date. This section is 

applicable beginning March 23, 2012. 

See § 147.140(d) of this chapter, 

providing that this section applies to 

grandfathered health plans. 

[FR Doc. 2011–21193 Filed 8–17–11; 11:15 am] 

BILLING CODE 4120–01–P 

DEPARTMENT OF THE TREASURY 

Internal Revenue Service 

26 CFR Part 54 

DEPARTMENT OF LABOR 

Employee Benefits Security 

Administration 

29 CFR Part 2590 

DEPARTMENT OF HEALTH AND 

HUMAN SERVICES 

[CMS–9982–NC] 

45 CFR Part 147 

Summary of Benefits and Coverage 

and Uniform Glossary—Templates, 

Instructions, and Related Materials 

Under the Public Health Service Act 

AGENCY: Internal Revenue Service, 

Department of the Treasury; Employee 

Benefits Security Administration, 

Department of Labor; Centers for 

Medicare & Medicaid Services, 

Department of Health and Human 

Services. 

ACTION: Solicitation of comments. 

SUMMARY: The Departments of the 

Health and Human Services, Labor, and 

the Treasury (the Departments) are 

simultaneously publishing in the 

Federal Register this document and 

proposed regulations (2011 proposed 

regulations) under the Patient Protection 

and Affordable Care Act to implement 

the disclosure for group health plans 

and health insurance issuers of the 

summary of benefits and coverage (SBC) 

and the uniform glossary. This 

document proposes a template for an 

SBC; instructions, sample language, and 

a guide for coverage examples 

calculations to be used in completing 

the template; and a uniform glossary 

that would satisfy the disclosure 

requirements under section 2715 of the 

Public Health Service (PHS) Act. 

Comments are invited on these 

materials. 

DATES: Comment Dates: Comments are 

due on or before October 21, 2011. 

ADDRESSES: Written comments may be 

submitted to any of the addresses 

specified below. Any comment that is 

submitted to any Department will be 

shared with the other Departments. 

Please do not submit duplicates. 

All comments will be made available 

to the public. Warning: Do not include 

any personally identifiable information 

(such as name, address, or other contact 

information) or confidential business 

information that you do not want 

publicly disclosed. All comments are 

posted on the Internet exactly as 

received, and can be retrieved by most 

Internet search engines. No deletions, 

modifications, or redactions will be 

made to the comments received, as they 

are public records. Comments may be 

submitted anonymously. 

Department of Labor. Comments to 

the Department of Labor, identified by 

RIN 1210–AB52, by one of the following 

methods: 

• Federal eRulemaking Portal: http:// 

www.regulations.gov. Follow the 

instructions for submitting comments. 

• E-mail: E–OHPSCA2715.EBSA

@dol.gov. 

• Mail or Hand Delivery: Office of 

Health Plan Standards and Compliance 

Assistance, Employee Benefits Security 

Administration, Room N–5653, U.S. 

Department of Labor, 200 Constitution 

Avenue NW., Washington, DC 20210, 

Attention: RIN 1210–AB52. 

Comments received by the 

Department of Labor will be posted 


jlentini on DSK4TPTVN1PROD with PROPOSALS2
52476 Federal Register / Vol. 76, No. 162 / Monday, August 22, 2011 / Proposed Rules 

1The Affordable Care Act also adds section 

715(a)(1) to the Employee Retirement Income 

Security Act (ERISA) and section 9815(a)(1) to the 

Internal Revenue Code (the Code) to incorporate the 

provisions of part A of title XXVII of the PHS Act 

into ERISA and the Code, and make them 

applicable to group health plans, and health 

insurance issuers providing health insurance 

coverage in connection with group health plans. 

without change to http:// 

www.regulations.gov and http:// 

www.dol.gov/ebsa, and available for 

public inspection at the Public 

Disclosure Room, N–1513, Employee 

Benefits Security Administration, 200 

Constitution Avenue, NW., Washington, 

DC 20210. 

Department of Health and Human 

Services. In commenting, please refer to 

file code CMS–9982–NC. Because of 

staff and resource limitations, we cannot 

accept comments by facsimile (FAX) 

transmission. 

You may submit comments in one of 

four ways (please choose only one of the 

ways listed): 

1. Electronically. You may submit 

electronic comments on this regulation 

to http://www.regulations.gov. Follow 

the instructions under the ‘‘More Search 

Options’’ tab. 

2. By regular mail. You may mail 

written comments to the following 

address ONLY: Centers for Medicare & 

Medicaid Services, Department of 

Health and Human Services, Attention: 

CMS–9982–NC, P.O. Box 8016, 

Baltimore, MD 21244–1850. 

Please allow sufficient time for mailed 

comments to be received before the 

close of the comment period. 

3. By express or overnight mail. You 

may send written comments to the 

following address ONLY: Centers for 

Medicare & Medicaid Services, 

Department of Health and Human 

Services, Attention: CMS–9982–NC, 

Mail Stop C4–26–05, 7500 Security 

Boulevard, Baltimore, MD 21244–1850. 

4. By hand or courier. If you prefer, 

you may deliver (by hand or courier) 

your written comments before the close 

of the comment period to either of the 

following addresses: 

a. For delivery in Washington, DC— 

Centers for Medicare & Medicaid 

Services, Department of Health and 

Human Services, Room 445–G, Hubert 

H. Humphrey Building, 200 

Independence Avenue, SW., 

Washington, DC 20201. 

(Because access to the interior of the 

Hubert H. Humphrey Building is not 

readily available to persons without 

Federal government identification, 

commenters are encouraged to leave 

their comments in the CMS drop slots 

located in the main lobby of the 

building. A stamp-in clock is available 

for persons wishing to retain a proof of 

filing by stamping in and retaining an 

extra copy of the comments being filed.) 

b. For delivery in Baltimore, MD— 

Centers for Medicare & Medicaid 

Services, Department of Health and 

Human Services, 7500 Security 

Boulevard, Baltimore, MD 21244–1850. 

If you intend to deliver your 

comments to the Baltimore address, 

please call (410) 786–9994 in advance to 

schedule your arrival with one of our 

staff members. 

Comments mailed to the addresses 

indicated as appropriate for hand or 

courier delivery may be delayed and 

received after the comment period. 

Submission of comments on 

paperwork requirements. You may 

submit comments on this document’s 

paperwork requirements by following 

the instructions at the end of the 

‘‘Collection of Information 

Requirements’’ section in this 

document. 

Inspection of Public Comments: All 

comments received before the close of 

the comment period are available for 

viewing by the public, including any 

personally identifiable or confidential 

business information that is included in 

a comment. We post all comments 

received before the close of the 

comment period on the following Web 

site as soon as possible after they have 

been received: http:// 

www.regulations.gov. Follow the search 

instructions on that Web site to view 

public comments. 

Comments received timely will also 

be available for public inspection as 

they are received, generally beginning 

approximately three weeks after 

publication of a document, at the 

headquarters of the Centers for Medicare 

& Medicaid Services, 7500 Security 

Boulevard, Baltimore, Maryland 21244, 

Monday through Friday of each week 

from 8:30 a.m. to 4 p.m. EST. To 

schedule an appointment to view public 

comments, phone 1–800–743–3951. 

Internal Revenue Service. Comments 

to the IRS, identified by REG–140038– 

10, by one of the following methods: 

• Federal eRulemaking Portal: http:// 

www.regulations.gov. Follow the 

instructions for submitting comments. 

• Mail: CC:PA:LPD:PR (REG–140038– 

10), room 5205, Internal Revenue 

Service, P.O. Box 7604, Ben Franklin 

Station, Washington, DC 20044. 

• Hand or courier delivery: Monday 

through Friday between the hours of 8 

a.m. and 4 p.m. to: CC:PA:LPD:PR 

(REG–140038–10), Courier’s Desk, 

Internal Revenue Service, 1111 

Constitution Avenue, NW., Washington 

DC 20224. 

All submissions to the IRS will be 

open to public inspection and copying 

in room 1621, 1111 Constitution 

Avenue, NW., Washington, DC from 9 

a.m. to 4 p.m. 

FOR FURTHER INFORMATION CONTACT: 

Amy Turner or Heather Raeburn, 

Employee Benefits Security 

Administration, Department of Labor, at 

(202) 693–8335; Karen Levin, Internal 

Revenue Service, Department of the 

Treasury, at (202) 622–6080; Jennifer 

Libster or Padma Shah, Centers for 

Medicare & Medicaid Services, 

Department of Health and Human 

Services, at (301) 492–4252. 

Customer Service Information: 

Individuals interested in obtaining 

information from the Department of 

Labor concerning employment-based 

health coverage laws may call the EBSA 

Toll-Free Hotline at 1–866–444–EBSA 

(3272) or visit the Department of Labor’s 

Web site (http://www.dol.gov/ebsa). In 

addition, information from HHS on 

private health insurance for consumers 

can be found on the Centers for 

Medicare & Medicaid Services (CMS) 

Web site (http://www.cms.hhs.gov/ 

HealthInsReformforConsume/ 

01_Overview.asp) and information on 

health reform can be found at http:// 

www.healthcare.gov. 

SUPPLEMENTARY INFORMATION: 

I. Introduction 

The Departments of Health and 

Human Services (HHS), Labor, and the 

Treasury (the Departments) are taking a 

phased approach to issuing regulations 

and guidance implementing the revised 

Public Health Service Act (PHS Act) 

sections 2701 through 2719A and 

related provisions of the Patient 

Protection and Affordable Care Act 

(Affordable Care Act).1 Section 2715 of 

the PHS Act directs the Departments to 

develop standards for use by a group 

health plan and a health insurance 

issuer in compiling and providing a 

summary of benefits and coverage (SBC) 

that ‘‘accurately describes the benefits 

and coverage under the applicable plan 

or coverage.’’ Section 2715 of the PHS 

Act also directs the Departments to 

provide for the development of a 

uniform glossary. The statute directs the 

Departments, in developing such 

standards, to ‘‘consult with the National 

Association of Insurance 

Commissioners’’ (referred to in this 

document as the ‘‘NAIC’’), ‘‘a working 

group composed of representatives of 

health insurance-related consumer 

advocacy organizations, health 

insurance issuers, health care 

professionals, patient advocates 

including those representing 


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Federal Register / Vol. 76, No. 162 / Monday, August 22, 2011 / Proposed Rules 52477 

2A list of the NAIC working group members can 

be found at: http://www.naic.org/documents/

committees_b_consumer_information_contacts.pdf. 

3Records and other information relating to all of 

the meetings held by the NAIC working group can 

be found at: http://www.naic.org/committees_

b_consumer_information.htm. 

4The NAIC consulted readability experts and 

conducted consumer testing. The SBC format was 

designed to enhance to consumer understanding 

and usability. For example, use of vocabulary, such 

as ‘‘don’t’’ verses ‘‘do not’’ reflects intentional 

design based on feedback from consumer testing. 

These format choices reflect in part, the NAIC’s 

efforts to address the statutory requirement that the 

form be ‘‘culturally and linguistically appropriate.’’ 

5Summaries of this consumer testing are 

available at: http://www.naic.org/documents/

committees_b_consumer_information_101012_

ahip_focus_group_summary.pdf; http://www.naic.

org/documents/committees_b_consumer_

information_110603_ahip_bcbsa_consumer_

testing.pdf; http://www.naic.org/documents/

committees_b_consumer_information_

101014_consumers_union.pdf (a more detailed 

summary of which is accessible at: http:// 

prescriptionforchange.org/pdf/CU_Consumer_

Testing_Report_Dec_2010.pdf); and http:// 

www.naic.org/documents/committees_b_consumer_

information_110603_consumers_union_testing.pdf. 

6 In their materials, the NAIC uses the phrase 

‘‘Summary of Coverage’’ to describe the SBC 

template. However, the Departments use the term 

‘‘Summary of Benefits and Coverage’’ in the 

proposed regulations and this document. Both of 

these terms are meant to refer to the same document 

(located in Appendix A–1 of this document). 

7National Association of Insurance 

Commissioners, Consumer Information Working 

Group, December 17, 2010 Letter to the Secretaries. 

Available at http://www.naic.org/documents/

committees_b_consumer_information_ppaca_letter_

to_sebelius.pdf. 

individuals with limited English 

proficiency, and other qualified 

individuals.’’ 

As part of this required consultation, 

the NAIC convened the Consumer 

Information (B) Subgroup (NAIC 

working group), comprised of a diverse 

group of stakeholders.2 This working 

group met frequently each month for 

over one year while developing its 

recommendations. The NAIC working 

group created two subgroups—one 

focused on developing a uniform 

glossary of health insurance and 

medical terms and the other focused on 

developing standards for the SBC. All 

drafts were discussed and agreed to by 

the entire NAIC working group and then 

submitted to the full NAIC membership 

for a vote to submit the drafts as 

recommendations to the Departments. 

Throughout the process, NAIC working 

group draft documents and meeting 

notes were displayed on the NAIC’s 

Web site for public review, and several 

interested parties filed formal 

comments. In addition to participation 

from the NAIC working group members, 

conference calls and in-person meetings 

were open to other interested parties 

and individuals and provided an 

opportunity for non-member feedback. 

The NAIC indicates that stakeholders 

from a diverse pool of backgrounds 

participated in working group 

conference calls.3

As a result of this process, the NAIC 

working group recommended use of a 

uniform SBC template, as well as a 

uniform glossary, for the individual and 

group insurance markets. In developing 

these recommendations, the draft SBC 

template, including the coverage 

examples, and the draft uniform 

glossary underwent consumer testing,4

sponsored by both consumer and 

insurance industry groups. These tests 

were intended to assist in determining 

necessary adjustments to ensure the 

final product was consumer friendly.5

The Departments have received 

transmittals from the NAIC that include 

a recommended template for the SBC 

(referred to in this document as the 

‘‘SBC template’’) 6 with instructions, 

samples, and a guide for coverage 

examples calculations to be used in 

completing the SBC template. The NAIC 

transmittals also included a 

recommended uniform glossary of 

coverage and medical terms (referred to 

in this document as the ‘‘uniform 

glossary’’). The SBC template and 

uniform glossary include modifications 

made by the NAIC working group in 

response to the results of extensive 

consumer testing. 

The 2011 proposed regulations and 

this document follow the 

recommendations made by the NAIC 

and incorporate the documents drafted 

by the NAIC, including the SBC 

template (with instructions, sample 

language, and a guide for coverage 

examples calculations to be used in 

completing the SBC template) and the 

uniform glossary. The Appendices do 

not include a sample coverage example 

calculation for breast cancer in the 

individual market that was transmitted 

by the NAIC. Upon review, it appeared 

that some of the data in the example 

might be subject to copyright protection. 

Moreover, the sample coverage example 

calculation provided by the NAIC was 

limited to breast cancer in the 

individual market and did not address 

the other two coverage examples— 

maternity coverage and diabetes. 

Finally, particular coding information 

and pricing information included in the 

sample would change annually, which 

would result in the data included in the 

sample becoming outdated relatively 

quickly. Accordingly, HHS is publishing 

on its Web site (at http://cciio.cms.gov) 

the coding and pricing information 

necessary to perform coverage example 

calculations for all three coverage 

examples. HHS will update this 

information annually. 

Instead of proposing possible changes 

to the NAIC’s proposed SBC template 

and related materials at this time, this 

document proposes to incorporate the 

NAIC working group’s recommended 

materials as transmitted (with the 

exception of the sample coverage 

example, explained above), and invites 

public comment. The Departments 

recognize that changes to the SBC 

template may be appropriate to 

accommodate various types of plan and 

coverage designs, to provide additional 

information to individuals, or to 

improve the efficacy of the disclosures 

recommended by the NAIC. In addition, 

the SBC template and related 

documents were drafted by the NAIC 

primarily for use by health insurance 

issuers.7 The NAIC states in its 

transmittal letter that additional 

modifications may be needed for some 

group health plans. Consequently, 

comments are requested on these issues 

specifically and on the SBC template, 

sample completed SBC, instructions for 

both group health plan coverage and 

individual health insurance coverage, 

sample language for the ‘‘Why this 

Matters’’ section of the SBC, guide for 

coverage examples calculations, and on 

the uniform glossary generally. After the 

public comment period, the 

Departments will finalize these 

documents. Consistent with PHS Act 

section 2715(c), the Departments will 

periodically review and update these 

documents as appropriate, taking into 

account public comments. 

II. Proposal 

This document proposes an SBC 

template (with instructions, samples, 

and a guide for coverage examples 

calculations to be used in completing 

the SBC template), and the uniform 

glossary, to comply with the disclosure 

requirements of PHS Act section 2715, 

as authorized by the Departments 

pursuant to paragraph (a)(4) of the 2011 

proposed regulations. The SBC 

template, sample completed SBC, 

instructions for both group health plan 

coverage and individual health 

insurance coverage, sample language for 

the ‘‘Why This Matters’’ section of the 

SBC, guide for coverage examples 

calculations, and uniform glossary are 

identical to the documents transmitted 

by the NAIC. These items are contained 

in the Appendices to this document. 

In addition to the materials in the 

Appendices that are proposed in this 

document, HHS is providing (at http:// 

cciio.cms.gov) the specific information 

necessary to simulate benefits covered 

under the plan or policy for the 


jlentini on DSK4TPTVN1PROD with PROPOSALS2
52478 Federal Register / Vol. 76, No. 162 / Monday, August 22, 2011 / Proposed Rules 

8PHS Act section 2715(b)(3)(G) provides that this 

statement must indicate whether the plan or 

coverage (1) provides minimum essential coverage 

(as defined under section 5000A(f) of the Code) and 

(2) ensures that the plan’s or coverage’s share of the 

total allowed costs of benefits provided under the 

plan or coverage is not less than 60 percent of such 

costs. 

9See http://www.dol.gov/ebsa or http:// 

cciio.cms.gov. 

10As defined in 26 CFR 54.9801–2, 29 CFR 

2590.701–2, and 45 CFR 144.103, COBRA means 

Title X of the Consolidated Omnibus Budget 

Reconciliation Act of 1985, as amended. 

coverage examples portion of the SBC 

(including specific medical items and 

services, dates of service, billing codes, 

and allowed charges for each claim in 

the three specified benefits scenarios). 

HHS will update this information 

annually on its Web site. The 

Departments propose that plans and 

issuers are not required to update their 

coverage examples for SBCs provided 

before the date that is 90 days after the 

date that HHS provides this updated 

information. That is, 90 days after HHS 

updates the information, SBCs that are 

otherwise required to be provided under 

paragraph (a) of the proposed rules 

should take into account the new 

information when providing coverage 

examples. For example, if HHS releases 

updated information on September 15 of 

a year, SBCs required to be provided on 

or after December 14 of that year under 

the rules of paragraph (a) of the 

proposed rules would need to include 

coverage examples calculated using the 

new information. However, these 

updates alone will not be considered a 

material modification under paragraph 

(b) of the 2011 proposed regulations. 

Comments are invited on this 

information as well, including the 

annual update provision. The preamble 

to the 2011 proposed regulations 

contains a request for comment 

regarding various approaches to 

providing the coverage examples. 

Commenters addressing the requirement 

to provide updated coverage examples 

are encouraged to consider how updates 

would be made to the coverage 

examples under these various 

approaches and what additional 

instructions should be added to address 

updates and a possible phased-in 

approach to implementation discussed 

in the preamble to the 2011 proposed 

regulations. 

With respect to the element of the 

SBC regarding a statement about 

whether a plan or coverage provides 

minimum essential coverage (as defined 

under section 5000A(f) of the Code) and 

whether the plan’s or coverage’s share of 

the total allowed costs of benefits 

provided under the plan or coverage 

meets applicable minimum value 

requirements (minimum essential 

coverage statement),8 because this 

content is not relevant until other 

elements of the Affordable Care Act are 

implemented, this statement is not in 

the NAIC recommendations. For the 

same reason, and as discussed more 

fully in the preamble to the 2011 

proposed regulations, the minimum 

essential coverage statement is not 

required to be in the SBC until the plan 

or coverage is required to provide an 

SBC with respect to coverage beginning 

on or after January 1, 2014. As provided 

in the preamble to the 2011 proposed 

regulations, comments are requested on 

how employers might provide the 

information included in the minimum 

essential coverage statement and other 

plan-level reporting in a manner that 

minimizes duplication and burden. 

In addition, the SBC template 

recommended by the NAIC and located 

in Appendix A–1 of this document 

includes Web sites for individuals to 

access the uniform glossary, for 

information about prescription drug 

coverage, and for information about the 

plan or coverage provider network. The 

Departments note, however, these Web 

sites are not working Web sites. Plans 

and issuers would need to modify this 

aspect of the SBC template to include 

relevant, working Web addresses (for 

the uniform glossary, this may be the 

Web address of either the Department of 

Labor or HHS Web site, or on the plan’s 

or issuer’s own Web site). The 

Departments invite comment on 

whether this statement in the SBC 

template regarding the electronically 

available uniform glossary should be 

modified to include a statement that the 

uniform glossary is available in paper 

form upon request. 

III. Solicitation of Comments 

The Departments solicit comments 

generally on the SBC template and 

related documents and the uniform 

glossary included in the Appendices, as 

well as on specific issues set forth below 

(including on what modifications, if 

any, are needed for group health plans 

to use the SBC template). 

The NAIC stated in the December 

2010 transmittal letter that the working 

group intentionally designed the layout 

and color of the SBC template based on 

consumer testing to make the document 

more readable and to facilitate 

comparison of different plan and 

coverage options. The Departments 

recognize, however, that color printing 

may be costly for some plans and 

issuers and therefore propose that a plan 

or issuer will be compliant if it uses 

either the color version (available on the 

Web sites of the Departments of Labor 

and HHS),9 as recommended by the 

NAIC, or the grayscale version (included 

in the Appendices to this document). In 

addition, the Departments note that 

while the NAIC-recommended SBC 

template is only three double-sided 

pages, the Departments are proposing 

that a completed SBC may be four 

double-sided pages in length. The SBC 

template reserves space to ensure that a 

plan or issuer with different benefit 

designs (such as multiple, tiered 

provider networks) could provide all the 

necessary information, and that 

additional coverage examples could be 

added in the future, within four doublesided pages. (See the preamble to the 

2011 proposed regulations for a request 

for comment regarding various 

approaches to providing the coverage 

examples.) 

The Departments are interested in any 

general comments regarding the 

proposed SBC template, sample 

completed SBC, instructions for both 

group health plan coverage and 

individual health insurance coverage, 

sample language for the ‘‘Why This 

Matters’’ section of the SBC, guide for 

coverage examples calculations, and 

uniform glossary. In making this request 

for comment, the Departments note that 

the purpose of PHS Act section 2715 is 

to provide individuals and plan 

participants with a brief summary of 

plan or policy benefits and coverage so 

that they may more easily compare 

health care coverage and better 

understand the terms of coverage (or 

exceptions to the coverage). The SBC is 

intended to assist individuals 

purchasing coverage in the individual 

market in comparing the benefits and 

coverage of different individual policies 

offered by insurance issuers. Likewise, 

the SBC is intended to assist employees 

who are offered group coverage to 

compare among different employerprovided health care options or to 

compare their employer’s options with 

other coverage for which they may be 

eligible, such as a spouse’s or 

dependent’s offer of employer-provided 

health care coverage, a former 

employer’s COBRA continuation 

coverage,10 or a policy on the individual 

market. 

In order to make it as easy as possible 

for individuals to understand the terms 

of their own coverage and compare 

coverage and benefits efficiently and 

accurately, the statute provides for, and 

the NAIC recognized the importance of, 

presenting the SBC in a uniform format. 

We invite comments on how this 

statutory requirement should be 


jlentini on DSK4TPTVN1PROD with PROPOSALS2
Federal Register / Vol. 76, No. 162 / Monday, August 22, 2011 / Proposed Rules 52479 

11Note: The general notice of preexisting 

condition exclusion and the individual notice of 

preexisting condition exclusion at 26 CFR 54.9801– 

3(c) and (e), 29 CFR 2590.701–3(c) and (e), and 45 

CFR 146.111(c) and (e), were published as part of 

the Departments’ HIPAA portability regulations on 

December 30, 2004, 69 FR 78720. 

12Note: Under paragraph (a)(2) of the 

Departments’ interim final regulations regarding 

status as a grandfathered health plan, to maintain 

grandfather status, group health plans and health 

insurance coverage must include a statement in any 

plan materials describing the benefits provided that 

the plan or coverage believes it is a grandfathered 

health plan. Model language is provided. See 26 

CFR 54.9815–1251T(a)(2), 29 CFR 2590.715– 

1251(a)(2), and 45 CFR 147.140(a)(2), published in 

the Federal Register on June 17, 2010, 75 FR 34538. 

applied, including the nature and extent 

of the uniformity that should be 

required in the specific language of the 

SBC and the manner and sequence in 

which the information in the SBC is 

presented. We ask that any comments 

proposing that flexibility be permitted 

in aspects of the presentation of the SBC 

explicitly address the potential positive 

or negative effects on individuals’ 

ability to effectively compare benefits 

and coverage among and across 

individual policies and group health 

plans. 

The Departments also invite 

comments on the following specific 

issues: 

1. The SBC template is intended to be 

used by all types of plan or coverage 

designs. The Departments are interested 

in comments related to issues that may 

arise from the use of this template for 

different types of plan or coverage 

designs (for example, designs using 

tiered provider networks or group 

health plans that may use multiple 

issuers or service providers to provide 

or administer different categories of 

benefits within a benefit package). 

2. The Departments are interested in 

comments regarding any modifications 

needed for use by group health plans 

(e.g., with respect to disclosure 

regarding cost of coverage and changes 

in terminology required for self-insured 

plans, such as use of the term ‘‘plan 

year’’ instead of ‘‘policy period’’). 

3. The Departments are interested in 

comments regarding whether the 

content of the SBC should require 

inclusion of additional information, 

such as information regarding any 

preexisting condition exclusion under 

the plan or policy,11 status as a 

grandfathered health plan,12 or other 

information that might be important for 

individuals to know about their 

coverage and how the SBC template 

could be modified to ensure effective 

disclosure of these additional elements, 

while respecting the statutory 

formatting requirements. For example, 

comments are requested on whether a 

simplified reporting method, such as a 

checkbox, could be used to disclose 

preexisting condition exclusions and 

grandfather status. 

4. The fourth page of the SBC 

template includes a list of services that 

plans and issuers must indicate as either 

excluded or covered in the ‘‘Excluded 

Services & Other Covered Services’’ 

chart. The Departments solicit 

comments on whether services should 

be added or removed from this list, as 

well as whether the disclosure stating 

that the list is not complete is adequate. 

5. The SBC template includes a 

disclosure on the first page indicating to 

consumers that the SBC is not the actual 

policy and does not include all of the 

coverage details found in the actual 

policy. The Departments solicit 

comments on whether this disclosure is 

adequate. 

The uniform glossary is also included 

in Appendix E of this document. The 

Departments propose that plans and 

issuers cannot make any modifications 

to this glossary. The uniform glossary 

was developed to facilitate and enhance 

consumer comprehension and is not 

intended to provide legal or contractual 

definitions that necessarily apply 

accurately, without modification, to 

every plan or coverage. The NAIC 

consumer testing found that certain 

terms relating to cost-sharing provisions 

were particularly difficult for consumers 

to understand. As a result, the NAIC 

developed diagrams to accompany the 

textual definitions of these terms. The 

Departments solicit comments on the 

uniform glossary, including its terms 

and definitions, and whether other 

terms should be added to the glossary, 

as well as whether any of the terms 

would be considered inaccurate or 

misleading based on a particular plan or 

coverage design. 

Comments are also invited on the 

standards set forth in the 2011 proposed 

regulations. To comment on the 2011 

proposed regulations, see the comment 

section of the 2011 proposed 

regulations, published elsewhere in this 

issue of the Federal Register. 

IV. Paperwork Reduction Act 

According to the Paperwork 

Reduction Act of 1995 (Pub. L. 104–13) 

(PRA), no persons are required to 

respond to a collection of information 

unless such collection displays a valid 

OMB control number. The Department 

notes that a Federal agency cannot 

conduct or sponsor a collection of 

information unless it is approved by 

OMB under the PRA, and displays a 

currently valid OMB control number, 

and the public is not required to 

respond to a collection of information 

unless it displays a currently valid OMB 

control number. See 44 U.S.C. 3507. 

Also, notwithstanding any other 

provisions of law, no person shall be 

subject to penalty for failing to comply 

with a collection of information if the 

collection of information does not 

display a currently valid OMB control 

number. See 44 U.S.C. 3512. 

This document relates to the 

information collection request (ICR) 

contained in a proposed regulation 

titled ‘‘Summary of Benefits and 

Coverage and the Uniform Glossary,’’ 

which is published elsewhere in today’s 

issue of the Federal Register. For a 

discussion of the hour and cost burden 

associated with the ICR, please see the 

notice of proposed rulemaking. 

Sarah Hall Ingram, 

Acting Deputy Commissioner for Services and 

Enforcement, Internal Revenue Service. 

Signed this 15th day of August, 2011. 

Phyllis C. Borzi, 

Assistant Secretary, Employee Benefits 

Security Administration, Department of 

Labor. 

Dated: July 28, 2011. 

Donald Berwick, 

Administrator, Centers for Medicare & 

Medicaid Services. 

Dated: August 9, 2011. 

Kathleen Sebelius, 

Secretary, Department of Health and Human 

Services. 

V. Appendices 

Table of Contents 

A. Summary of Benefits and Coverage (SBC) 

Appendix A–1. SBC Template 

Appendix A–2. Sample Completed SBC 

(Individual Health Insurance Coverage) 

B. Instructions for Completing the SBC 

Appendix B–1. Instructions—Group Health 

Plan Coverage 

Appendix B–2. Instructions—Individual 

Health Insurance Coverage 

C. Sample Language—Why This Matters 

section of SBC (Page 1) 

Appendix C–1. Why This Matters language 

for ‘‘Yes’’ Answers 

Appendix C–2. Why This Matters language 

for ‘‘No’’ Answers 

D. Coverage Examples Calculations 

Appendix D. Guide for Coverage Examples 

Calculations 

E. Uniform Glossary 

Appendix E. Uniform Glossary of Coverage 

and Medical Terms 

Overview of Appendices 

As stated earlier in this document, the 

NAIC transmitted the work of the NAIC 

Working Group to the Departments. The 

Appendices to this document include 

the SBC documents drafted by the NAIC 

in their entirety, with the exception of 

the sample coverage example 

calculation for breast cancer in the 


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individual market, as explained earlier 

in this document. 

Appendix A–1 contains an SBC 

template, as developed by the NAIC 

Working Group. The NAIC Working 

Group incorporated all of their 

recommendations contained in the 

multiple transmittals to the Departments 

over the last several months in their 

final recommended SBC template. 

Appendix A–2 contains a sample 

completed SBC, using information for a 

sample individual health insurance 

policy. While the sample completed 

SBC may not align perfectly with the 

instructions in every way, the document 

is useful in providing a general 

illustration of a completed SBC for a 

sample insurance policy. 

Appendices B–1 and B–2 contain 

instructions for group health coverage 

and individual health insurance 

coverage, respectively, to use in 

completing the SBC template. The 

Departments are publishing the sample 

completed SBC and the instructions to 

facilitate compliance with the 

requirements of the 2011 proposed 

regulations and this document. 

The SBC instructions include 

language that must be used when 

completing the ‘‘Why This Matters’’ 

column on the first page of the SBC 

template. Depending on the design of 

the policy or plan, there are two 

language options provided in 

Appendices C–1 (for when the answer 

in the applicable row is ‘‘yes’’) and C– 

2 (for when the answer in the applicable 

row is ‘‘no’’). Appendices C–1 and C–2 

provide an example of how this column 

will look when populated with the 

required language, as applicable 

depending upon the terms of the plan or 

coverage. 

Appendix D contains a guide for use 

by a plan or issuer in compiling 

information related to the coverage 

examples. This document, together with 

information provided in Microsoft Excel 

format by HHS at http://cciio.cms.gov, 

comprises all the information necessary 

to perform coverage example 

calculations for all three coverage 

examples. HHS will update the 

information on its Web site annually. 

With respect to these annual updates, 

the Departments propose that 90 days 

after HHS updates the information, 

SBCs that are otherwise required to be 

provided under paragraph (a) of the 

2011 proposed rules would take into 

account the new information when 

providing coverage examples. 

Finally, Appendix E contains the 

Uniform Glossary of Health Insurance 

and Medical Terms. 

The Departments invite comments on 

all of the documents in the Appendices 

to this document and their use in 

relation to the requirements of the 2011 

proposed regulations and this 

document. 

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[FR Doc. 2011–21192 Filed 8–17–11; 11:15 am] 

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