After logging in to ftwilliam.com, go to the "Print Plan Documents / Admin Forms" page for a HRA or Cafeteria plan that indicated the Summary Plan Description should include HIPAA portability language. You should see the SBC ("SBC - Annual") under the "Forms" box.

The SBC form once created from the ftwilliam.com system will require minimal editing for the majority of Cafeteria and HRA plans. All plans will need to review the first two items listed below. In item 3, we are bringing your attention to a modification we have made from the SBC template. Items 4-6 may be applicable to some plans and may require modification of the SBC. We assume the majority of plans will not need modifications for items 4-6.

1. Coverage Period

   The coverage period must be entered in the format __/__/____ – __/__/____. See the headers on page 1 and 7 of the SBC (the header is reformatted at page 7 and so requires editing in both places).

   The batch software will calculate the coverage begin and end dates based upon the plan year end information entered in the checklist and the current date. The coverage dates will be editable in the batch grid.

2. Contact information

   The SBC has been completed to the extent possible with the current HRA/Cafeteria plan information in the ftwilliam.com system. Where contact phone numbers are required, we have pre-populated with the phone number currently used for claims (checklist item J.5). The SBC does have several locations for a web address ("www.[insert]" at top of page one and in the footer of the document) - these should be completed manually in the file once it is created from the system.

   Note: the SBC regulations do not appear to require a web address to obtain a copy of the plan or for questions but the instructions to complete the SBC state the plan "must insert the appropriate telephone number and website information" in the footer and "should insert a website and telephone number" for accessing copies of the plan. We have therefore left the website information to be edited once the SBCs are created.

   The batch software will have data entry grids to complete the website information as well as to specify other contact information throughout the notice (other than that used in J.5 of the checklist).

3. Excluded Services & Other Covered Services

   We have added a "Note" on page 5 of the SBC (under the SBC heading "Excluded Services & Other Covered Services") that does not appear in the model to help cover some circumstances common to HRAs and Cafeteria plans that we think should be clarified in the SBC but do not logically fit anyplace else in the model. All SBCs will see the text "Please Note: This plan provides reimbursements only" on page 5 of the SBC. If conditions or limitations apply to the plan such as coordination with HSAs for certain participants, coordination with HRAs or Cafeteria plans, or coverage limited to health plan deductibles/copays this information will also appear in the note.

4. Special Definitions of Eligible Expenses

   Cafeteria plans and HRAs with special definitions of Eligible Expenses - in particular, HRAs that use the option "Listed medical expenses" or "Schedule of expenses" (C.1a of the checklist) to define eligible expenses - should review the SBC to ensure the services described as covered or not covered are accurate.

   Pages 2-4 of the SBC list common medical events we assume most HRAs and Cafeteria plans will reimburse up to the amount available in the Participant's account. A complete list of these services is as follows:

   Primary care visit to treat an injury or illness
   Specialist visit
   Other practitioner office visit
   Preventive care/screening/immunization
   Diagnostic test (x-ray, blood work)
   Imaging (CT/PET scans, MRIs)
   Prescription drugs
   Over the counter drugs [SBC clarifies reimbursed "only if you have a prescription"]
   Facility fee (e.g., ambulatory surgery center)
   Physician/surgeon fees
   Emergency room services
   Emergency medical transportation
   Urgent care
   Facility fee (e.g., hospital room)
   Physician/surgeon fee
   Mental/Behavioral health outpatient services
   Mental/Behavioral health inpatient services
   Substance use disorder outpatient services
   Substance use disorder inpatient services
   Prenatal and postnatal care
   Delivery and all inpatient services
   Home health care
   Rehabilitation services
   Habilitation services
   Skilled nursing care
   Durable medical equipment
   Hospice service
   

   Page 5 of the SBC is required to include charts of covered and not covered services. The guidance provides a specific list (copied below) of services that must be categorized as covered or not covered. According to the instructions, the list must be in alphabetical order and each item must be listed separately with a bullet point.

   Acupuncture
   Bariatric surgery
   Chiropractic care
   Cosmetic surgery [Always categorized as "Not Covered"]
   Dental care (Adult)
   Hearing aids
   Infertility treatment
   Long-term care [Categorized as "Not Covered" for Cafeteria plans and HRAs using the FSA failsafe option]
   Non-emergency care when traveling outside the U.S.
   Routine eye care (Adult)
   Private-duty nursing
   Routine foot care
   Weight loss programs
   

   HRAs that use the option "Listed medical expenses" or "Schedule of expenses" presumably differ from the typically very broad category of eligible expenses in most cafeteria and HRA plans. For these plans, we will list the eligible expenses as entered in the checklist in the "Covered Services" chart on page 5 of the SBC and place all the items above in the category "Not Covered". We assume the SBC will require some editing once it has been created in these circumstances.

   The batch software grids will display plan information for these checklist items to help flag plans that have these special coverage situations and may require extensive editing of the SBC.

5. Foreign Language Access Services

   Group health plans offering non-grandfathered health insurance coverage must provide relevant notices in a culturally and linguistically appropriate manner. The regulations require these plans and issuers to make certain accommodations for notices sent to an address in a county where 10 percent or more of the population are literate only in the same non-English language. See http://www.cciio.cms.gov/resources/factsheets/clas-data.html for a list of applicable counties. Plans/issuers must provide oral language services in the applicable non-English language (i.e. a phone number).

   Affected non-grandfathered plans should add the heading "Language Access Services:" on page 6 of the SBC and the applicable foreign language text (see the model SBC www.dol.gov/ebsa/correctedsbctemplate.doc for details).

   The batch software grids will allow users to select applicable languages and enter a contact phone number.

6. Consumer Assistance Programs

   Page 6 of the SBC displays information about grievance and appeals rights. The SBC instructions state:

   If applicable in your state insert: “Additionally, a consumer assistance program can help you file your appeal. Contact [insert contact information].” A list of states with Consumer Assistance Programs is available at www.dol.gov/ebsa/healthreform and http://cciio.cms.gov/programs/consumer/capgrants/index.html.

   If the consumer assistance programs apply in the plan's state you may want to consider editing the SBC to add the applicable information. At this time we do not anticipate providing a software solution to add this information into the SBC.

When must SBCs be provided?

On the first day of the first open enrollment period that begins on or after September 23, 2012.

For participants and beneficiaries who enroll in coverage other than through an open enrollment period (most HRA plans), the SBC must be provided beginning on the first day of the first plan year that begins on or after September 23, 2012.

SBCs must also be provided:

• Annually during open enrollment/30 days prior to first day of plan year
• 90 days from enrollment for special enrollees during plan year – same as SPD requirement
• Upon request (7 days), application for benefits (7 days)
• By first day of coverage, if there are changes

What are the penalties for not providing an SBC?

Penalties may be as much as $1,000 for each such failure to provide.