Summary of Benefits and Coverage (Uniform Coverage Document)


Under the Affordable Care Act (ACA), the Department of Health and Human Services (HHS) was required to develop standards for use by group health plans and health insurance issuers offering group or individual coverage in compiling and providing an accurate summary of benefits and explanation of coverage document to plan participants and beneficiaries, as well individuals and dependents.

Specific under this requirement, failure to do so will result in up to a $1,000 fine per enrollee for each failure. There is also a 60-day notice requirement when a health plan or issuer modifies the terms of the plan or coverage.  The HHS Secretary was required to consult with the statutorily set NAIC Working Group composed of consumer organizations, health care professionals, patient advocates and health insurance issuers, among other qualified individuals. HHS was required to develop the standards by March 23, 2011 with an original implementation date of March 23, 2012.

A final rule was published in the federal register on February 14, 2012. The rule requires group health plans and insurance issuers to implement the requirements beginning September 23, 2012 (with variations in the application dates and the requirements between the individual and group market segments).

Aetna’s take and action

Aetna is working to implement based on final regulatory direction.

Questions and answers

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