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June 25, 2015

HRB 111 - Supreme Court Opinion - King v. Burwell (article)

HRB110:  Final SBC Rules; IRS Releases Draft Versions of 1094/1095 Series Forms; Revised External Review Process 

Released June 19, 2015 I Download as a PDF

Final Summary of Benefits and Coverage Rules

The Affordable Care Act (ACA) requires individual and group health plans, including grandfathered plans, to provide a written summary of benefits and coverage (SBC) explaining certain aspects of health benefit coverage.


Six months ago, the ACA’s tri-governing agencies (Departments of Labor, Health and Human Services and Treasury) released some proposed changes to SBCs (see Proposed SBC Changes in CBIZ Health Reform Bulletin 105, 1/8/15).  On June 15, 2015, the agencies published final regulations.  The final rules generally adopt most of the proposed changes and focus more on distribution methods and timelines.  Following are some of the clarifications and highlights of the final rules.


  • Who provides the SBC?  Generally, for insured plans, SBCs are provided by insurer and plan administrator; this is a joint obligation.  The final regulations affirm that compliance by one entity is deemed compliance by the other.  If the insurer is providing the SBC, then the plan administrator does have an obligation to monitor compliance.  For self-funded plans, the plan administrator (generally, the plan sponsor unless the plan indicates otherwise) is responsible for issuing SBCs.  In addition, insurers and group health plans must make a uniform glossary of insurance terms available upon request by participants. 
  • SBC content.  With regard information required to be contained in an SBC, the Departments of Labor and Health and Human Services have model SBC templates, instructions and related material available on their websites.  The model SBC template includes the required elements and content.  It should be noted that the DOL’s website has two sets of model SBC forms posted – one set applies to SBCs issued before January 1, 2017, and another set contains proposed SBCs for use on or after January 1, 2017.  However, caution should be exercised in using the proposed SBC templates because the regulations indicate that the tri-agencies will collaborate with the National Association of Insurance Commissioners (NAIC) to finalize a new SBC template, which should be available later this year.  The finalized SBC template would then be used on the first day of the first plan year that begins on or after January 1, 2017. 

    The SBC must also include a statement about whether a plan meets minimum essential coverage standards and the minimum value standard. If an SBC does not contain this language, the final regulations clarify that this information must be included in the cover letter that is distributed to participants along with the SBC.
  • Timeframes for providing SBC.  There are five instances in which SBCs must be provided: upon application, by the first day of coverage, within 90 days of enrollment for special enrollees, upon contract renewal, and upon request.  The final regulations clarify that:
  • If an insurer provides the SBC prior to application for coverage, it would not be required to provide another SBC at the time application is made unless there is a change in the SBC content provided in the pre-application version.  
  • In the event that a plan sponsor is negotiating coverage terms following application, an updated SBC reflecting those finalized coverage terms need not be provided until the first day of coverage, unless otherwise requested.
  • Website access to underlying plan or policy. The final regulations require website posting of the actual underlying insurance policy. For insured group plans, the insurer is required to post the policy’s certificate of coverage on its website for on-line access by the plan sponsor, as well as by participants and beneficiaries. 
  • Enforcement.  A group health plan that willfully fails to provide the SBC to a participant or beneficiary could be subject to a fine up to $1,000 for each such failure.

Effective date.  The final regulations become effective August 17, 2015.  The changes made in the final regulations, such as timing of SBC distribution and website access to underlying policies, become applicable on the first day of the first plan year beginning on or after September 1, 2015 (January 1, 2016 for calendar year plan).


Draft 2015 versions of ACA Reporting Form 1094 and 1095 Series

The Internal Revenue Service (IRS) has released draft 2015 editions of the Form 1094 and 1095 series. These forms are used to satisfy the IRC Section 6056 and 6055 reporting requirements. Once the forms and related instructions are finalized by the IRS, presumably later this year, the 2015 forms will be used for the mandatory reporting for the 2015 calendar year, due in early 2016.


As background, employers subject to the employer shared responsibility requirement (those employing 50 or more full-time employees) are required to file an annual report to the IRS for purposes of determining individuals entitled to premium assistance, as well as determine whether an employer might be at risk for an IRC §4980H(a) no-coverage tax, or an IRC §4980H(b) inadequate or unaffordable tax.  Each applicable large employer must file the Form 1094-C (transmittal form) and Form 1095-C annually with the IRS, as well as provide the related Form 1095-C benefit statements to employees listed in the Form 1094-C. 


Insurers, self-funded plans and other providers of minimum essential coverage (MEC) are also required to file an annual report to the IRS for purposes of reporting individuals covered by MEC. This requirement applies without regard to plan size.  Insurers, self-funded plans and other providers of minimum essential coverage (MEC) file Form 1094-B and Form 1095-B to the IRS. 


A self-funded plan sponsor subject to employer shared responsibility requirements can accomplish its MEC reporting obligation by completing Form 1094-C and Parts I, II and III of Form 1095-C.  Self-funded plans that are not subject to shared responsibility requirements complete their obligation on the Form 1094-B and 1095-B.

Following are the draft 2015 forms released by the IRS:

  • Form 1094-B Transmittal of Health Coverage information Returns
  • Form 1095-B Health Coverage
  • Form 1094-C Transmittal of Employer-Provided Health Insurance Offer and Coverage Information Returns
  • Form 1095-C Employer-Provided Health Insurance Offer and Coverage

The 2015 draft forms, in large part, follow the 2014 versions.  Following are changes to note in the 2015 edition of the Form 1095-C:

  • The 2015 draft Form 1095-C adds a new field, titled “Plan Start Month”.  This new field is optional for 2015.  Filers can choose to add this field and provide plan year information to add this field and enter “00”, or, at their option, leave this new field out (thus using 2014 format).  For 2016 and beyond, this field will be required.
  • The 2015 form also includes a continuation sheet that filers use if they need to report coverage for more than six individuals.
  • For 2015, the indicator codes in Part II, Line 14 “Offer of Coverage” (as outlined in the 2014 instructions) will remain unchanged from the 2014 codes.  
  • Beginning in 2016 and beyond, filers will need to include two additional codes, if applicable.  These new indicator codes will indicate to the IRS and to full-time employees that the employer’s offer to the spouse is a conditional offer. 

Until final forms and instructions are issued, employers are still in a bit of a waiting game but steps should be taken now to ensure the ability to report in early 2016.


Background CBIZ Health Reform Bulletins


Revised External Review Procedures

The ACA requires individual and non-grandfathered group health plans, whether insured or self-funded, to provide for an internal claim and appeal process, as well as an external review process for coverage determinations and claims.  These rules added an external review requirement for ERISA plans and extended the claims, appeals and external review requirements to plans exempt from ERISA such as state and local government plans and church plans. 


With regard to the external review process, an individual who has received an adverse determination relating to his/her coverage or claim has the right to appeal to an independent third party.  Many states have an external appeals process in place.  In the event that a state does not require plans to follow an external review process, the federal external review procedure would be followed.  The federal procedures also govern self-funded plans exempt from state law and subject to ERISA. 


On June 15, 2015, the HHS’ Center for Consumer Information and Insurance Oversight (CCIIO) released an updated process for plans, including non-grandfathered group health plans and non-federal self-funded state and local government plans that elect the federal external review process.   Previously, plans were required to make the election via an HHS e-mail address.  Plans electing to utilize the federally-administered external review process must now do so by way of the Health Insurance Oversight System (HIOS), a web-based CMS portal.  The guidance sets forth the steps for electing the federal external review process depending upon whether the entity is a new or existing HIOS user.  


About the Author:  Karen R. McLeese is Vice President of Employee Benefit Regulatory Affairs for CBIZ Benefits & Insurance Services, Inc., a division of CBIZ, Inc.  She serves as in-house counsel, with particular emphasis on monitoring and interpreting state and federal employee benefits law.  Ms. McLeese is based in the CBIZ Kansas City office.


 The information contained herein is not intended to be legal, accounting, or other professional advice, nor are these comments directed to specific situations. The information contained herein is provided as general guidance and may be affected by changes in law or regulation. The information contained herein is not intended to replace or substitute for accounting or other professional advice. Attorneys or tax advisors must be consulted for assistance in specific situations. This information is provided as-is, with no warranties of any kind. CBIZ shall not be liable for any damages whatsoever in connection with its use and assumes no obligation to inform the reader of any changes in laws or other factors that could affect the information contained herein.



























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