Since the passing of the Patient Protection and Affordable Care act (PPACA), the healthcare industry has faced numerous challenges. One of these challenges is the creation of the summary of benefits (SBC) document. Health care providers not meeting the demands of this regulatory document face steep financial penalties. According to the PPACA, health care companies who fail to deliver SBC’s can face a $1,000 penalty for each SBC.

In order to ensure the SBC’s are being completed, many health care providers have been audited. According to Chuck Whitford, consultant at JRG advisors, “In 2013, more than 70 percent of audits resulted in fines or other corrective action. The most common triggers are participant complaints and incomplete or inconsistent information.” To avoid paying the steep fines, it is important to understand the four times you are required to produce SBC’s. These four times are:

  • Enrollment
  • Renewal time
  • Shopping health exchange website
  • On request.

Out of the four, the trickiest to implement is enrollment. According to the law, you must generate an SBC for each of your plans that you are offering, for example, if you offer an HMO plan and PPO, you will have to create a separate SBC for each plan. Besides creating an SBC for each plan, your employee may have beneficiaries who reside in a different address. If this is the case, you will have to generate separate SBC’s for each beneficiary who resides at a separate location. 

Besides cases during enrollment when you will have to create SBC’s for beneficiaries, special enrollment occurrences may also appear. For example, if your employee gets married, adopts a child or a child is born, you may have to create separate SBC’s for each beneficiary. In this case the SBC must be provided to the special employee within 90 days after the date of the special enrollment period. 

Another tricky time where you may have to create the SBC is when content in the SBC changes from eligibility to coverage. For example, if you have a new hire, you may have to generate a SBC detailing your plan. However, your employee is not eligible for enrollment until completion of a 90-day period. If there are any changes to the plan from hiring to eligibility, you will have to generate a new SBC to reflect the changes. 

Making sure that you understand when you are required to generate the SBC, as well as ensuring the data used on your SBC is errata free is essential if you want to avoid the repercussions of extensive audits. 

In order to accomplish this task in a timely manner, you should automate the creation of your SBC’s . Instead of painstakingly creating the SBC’s by hand, you should use a CCM such as Tango+ that allows you to create the SBC using a master-template approach. Since Tango+ also offers highly customizable approval-based-workflow configurations, you can ensure that your  Subject Matter Experts (SME) verify your data and help you avoid the costs of failed compliance.