Compliance is a permanent initiative affecting all member correspondence. The points covered in this article represent a set of common challenges that we’re seeing as health plans work toward compliance for Summary of Benefits and Coverage (SBC). We recommend organizations research all five areas fully prior to establishing a strategy.
1. Data Access and Association
When it comes to preparing data for SBC communications, many organizations have two challenges – identifying source data and mapping the calculations to the SBC template fields. The sources needed for SBC calculations are typically contained in a variety of systems across the organization. As a result, it can be a challenge to identify the location or owner of the particular data required. Once the data is identified, there are business rules and calculations that must be applied before mapping it to the appropriate fields in the SBC template. Without a proper staging process, managing SBC data is a merely difficult task in the short term – but a nearly impossible one for the long term. A centralized data mapping system is essential to effectively prepare and manage SBC data as the plans or requirements change over time.
2. Dynamic Formatting Requirements for the SBC Template
One of the greatest benefits of SBC communications is also one of the biggest challenges – data presentation consistency. The SBC template is a standard information structure used by the health insurance industry. The physical data layout is specific, including the maximum number of pages and the information types required on each. When presenting SBC information, these formatting characteristics apply whether the plan is a simple one or has large amounts of data to be summarized. With such a need for dynamic data formatting, typical word processing applications may not be adequate for complex SBC documents.
3. Adequate Calculator
With many insurers and a variety of plans, no one SBC calculator is standard or possible, and it is the insurer’s responsibility to provide accurate information to assist members and shoppers. The government-issued calculator is only provided as a sample guide for the first year of applicability. For instance, multiple formulary tier structures or varying claim assignments require calculations beyond the scope of the calculator guide. Therefore, insurers will want to create specific calculations that are appropriate for their specific plans.
4. Meeting Delivery Windows
Fourth, in addition to creating a compliant SBC document with accurate information, plans must also comply with delivery requirements and be in position to prove they have provided the necessary information to members and shoppers within defined timeframes. Many organizations are currently struggling to comply with SBC creation and have yet to truly address how they will integrate delivery and reporting capabilities.
5. Financial Risk Beyond Fines
In addition to fines for late SBC delivery, there can be a more significant risk associated with presenting benefit and cost information to shoppers ahead of a contract. The SBC information must be consistent throughout a relationship, including quotes, a contract, or claims adjudication. As insurers develop new plans and options, and when current plans change, it is important to have confidence that these revisions are reflected in the SBC system. Therefore, the SBC system must be fully integrated with customer engagement and member management processes.
The reality of the SBC mandate is that many organizations have implemented short term tactical solutions. Compliance is a long-term initiative and will affect the entire organization. The ideal strategy is a solution that enables plans to be compliant now but is scalable to meet the long-term more strategic requirements.