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Archive for tag: SBC

Investments in IT: Innovating for Competitive Advantage

February 19, 2013

At the beginning of every year, we steal a glance behind us to see how far we've come, and then focus on the road ahead. 2012 was a successful year for health insurance carriers, despite the Affordable Care Act imposing strict requirements on policy related documents. Although these requirements were fulfilled, many insurers were still left scrambling days before the deadline; showcasing a level of inflexibility within existing insurance IT systems. However, technology advancements promise sustainable solutions to this issue.

A recent Strategy Meets Action (SMA) survey showed that 70% of insurers plan to increase their IT spending between 2013 and 2016, and that these investments aim to contribute to optimizing company operations, effectively leveraging data analytics, and building flexible and scalable IT environments.

Furthermore, the latest User Conference. It was so well presented that I felt sharing some of my reflections was well deserved… so here are some highlights:

This was the 5^th year that CEI has held a user conference … hosted in their home town of Greenville, South Carolina. A beautiful town with a very eclectic mix of restaurants, bars and shops... The conference was attended by companies from various industries - so the pre-show industry roundtable breakout sessions allowed users with common interests and backgrounds to meet up and share their challenges, successes and different perspectives on their CRM projects.

Participating in the Insurance industry session, the pains around SBC compliance were clearly apparent amongst the health care providers … and discussions around a ... Read more

Summary of Benefits and Coverage – Deadline Looms

September 21, 2012

Over the past couple of weeks, I have been engaging in many discussions with health care providers around the country. As the September 23 deadline looms only a few days away, I have been getting two streams of comments.

The first are from our clients - praising us for the support and quick technology solutions offered and delivered by our teams in getting their companies compliant with SBC - well in advance of the deadline. The other is from health care providers who have been trying (some more aggressively and diligently than others, I must say) to cobble a solution together in time for the deadline. Ara Trembly mentions some "wiggle room" in his recent blog, and consensus in the industry seems to be in agreement. It seems the government imposed deadline will NOT be extended, but the "patrolling bodies" will allow for an informal grace period so long ... Read more

So Now You’re Compliant - What Next?

September 19, 2012

Now that the deadline for compliance with the ACA SBC (Affordable Care Act Summary of Benefits and Coverage) has passed, we thought it would be a good time to recap where the healthcare industry is at and what to expect (and do :-) next.

After working with many health insurance providers and spending a considerable amount of time on the various trade events and online discussion groups, the first thing that comes to mind are the vastly different level of challenges that people had to overcome. I remember Laurie from Ohio, responsible for a single and very simple plan, who basically just downloaded the form from the government web site and created her two (yes, 2!) SBCs to be fully ready and compliant. At the other end of the spectrum, we've helped clients tackle, in time for the September 24 deadline, the complexities involved in massively complex plans with anything from 1 up to 4 and more tiers and all kinds of exceptions built into the benefits over... Read more

It Is Not Too Late to Calculate - SBC Coverage Example Challenges

September 18, 2012

With D-Day for the first wave of requirements for providing your Summary of Benefits and Coverage and Universal Glossary of Terms fast approaching, you may be scrambling to ensure you are prepared for compliance. Over the past several months I have witnessed the undertakings of and provided assistance to carriers positioning themselves to comply with this aspect of the ACA. From these experiences, it has become evident that the most overwhelming and problematic aspect of the SBC to satisfy is the implementation the Coverage Example section of this document. In a nutshell, there is a requirement to provide cost sharing information that highlights the plan benefits and the patient obligations for two claims scenarios (maternity and diabetes management) based on pre-defined treatment transactions for each scenario. To help carriers perform the required calculation, HHS has provided a simplified coverage example calculator. While this calculator does help to validate co... Read more

SBC Updates and Calculator

July 4, 2012

In addition to a minor revision to the SBC template released in May, a coverage example calculator is available to simplify the completion of this section of the SBC. Visit here for information and to download. The calculator offers simplified logic to help you compute relevant costs and values that you need to fill-in a plan-specific SBC.

Also included is an Excel spreadsheet with pre-programmed formulas and data entry fields that will produce your plan members' costs. For a more integrated approach, you could also easily incorporate this calculator directly into your Xpertdoc solution to make the process even more seamless. Xpertdoc has already implemented a similar coverage example calculator complete with rounding rules as defined in the SBC requirements. In addition, we have integrated with insurers' source systems to extract claims rules to be able to calculate a plan member's obligations i... Read more

XML Schema for Summary of Benefits and Coverage

May 18, 2012

As part of the work we do with many health insurers in relationship to the September 2012 deadline to provide a unified and standardized Summary of Benefits and Coverage report, we've designed an XML schema which we believe should meet the requirements of the vast majority of implementations. The schema covers all the values to fill out the form with "Important Questions", "Answers", "Why it Matters", "Services you May Need", "Your cost if you use a…" for up to three tiers, "Limitations and Exceptions", "Excluded Services", "Other Covered Services" and the "Patient Pays" component of the Coverage Examples. The schema does not include values that can be derived as we feel the calculations, including the rounding rules, are best handled at the template level.

Recognizing this schema could be of use to the community beyond Xpertdoc clients and partners, we're happy to provide an XML sample and the schema itself as a free download. There's no strings attached,... Read more

SBC Example Calculations Part 2 - Rounding

May 11, 2012

The Affordable Care Act specifies a standardized format for a Summary of Benefits and Coverage (SBC) report which every health insurer and every group health plan must provide to enrollees and applicants. An interesting twist with this mandate is the requirement to provide coverage examples to show how a plan might cover medical care in two given situations: having a baby and managing Type 2 diabetes. The government provides a detailed claims history for both situations with assumed care costs for each transaction. The emitter of an SBC is then required to provide an estimate of what the patient would pay, taking into account deductibles, co-pays, co-insurance and limits or exclusions. The generated report contains clear indications that this is just an estimate, not an actual cost estimator, and that readers can't use the examples to estimate costs for an actual condition. They are for comparative purposes only.

In order to reinforce to consumers that numb... Read more

SBC Example Calculations Part 1 - Strategy

May 4, 2012

 The Affordable Care Act specifies a very precise and standardized format for a Summary of Benefits and Coverage report which every health insurer and every group health plan must provide to enrollees and applicants. This mandate comes with a very tight deadline of September 23^rd, 2012, which is having many organizations scrambling to become compliant in time.

The Xpertdoc cloud and on-premise solution for the SBC mandate has been production-ready since March 2012, and it effectively provides instant, out-of-the-box compliance while ensuring a robust and seamless roadmap for a deep integration with insurers and plans IT infrastructure.

As we engage with more and more organizations subjected to the mandate, one of the recurring headaches those responsible for compliance are sharing with us is the matter of the Coverage Calculation Examples. In a nutshell, the government has defined two very specific scenarios (one for maternity, one ... Read more

Imminence of the SBC

April 17, 2012

Summary of Benefits and Coverage - Soon to Be Compulsory

I recently became distracted from my regular routine by an undeniable force that seems to be taking health insurers by storm. Having worked in insurance technology for nearly 15 years, there are only a few times that I can recall observing a common theme invade the landscape of insurance like the SBC issue is currently doing. Perhaps only when Y2K was about to end the world did I notice an acronym strike such trepidation into the world of health insurance carriers.

I'll not proclaim to be an expert in the intricacies of the Affordable Care Act, but given the frequency of enquiries from our existing insurance customers and the general stir in the health insurance space, I took some time to review the legislation and think about its ramifications. In a nutshell, it seems that virtually all health insurance carriers will need to meet requirements established to provide clear and consistent co... Read more

Summary of Benefits and Coverage

March 15, 2012

A Tale of Government Mandate, Cloud and CRM

All group insurance providers operating in the US are mandated by the US Government to provide clear and consistent information to consumers about their health insurance coverage. The Affordable Care Act ensures consumers receive, in plain English, a Summary of Benefits and Coverage (SBC) on a standardized form that will help them understand and evaluate their health insurance choices. More details are available on this requirement on the HealthCare.gov web site.

Many health care insurance carriers are finding themselves in a bit of a scramble to meet the September 2012 compliance deadline. Xpertdoc is addressing this requirement with many carriers who are pleased to see the Xpertdoc Solution already allows them to rapidly comply with this regulation change, while providing a strong and solid... Read more