Amerihealth – Updates on SBC’s & Off-Anniversary Changes

Updates on the Summary of Benefits and Coverage

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We would like to share some important updates and reminders about the Summary of Benefits and Coverage (SBC), under the Affordable Care Act (ACA), including information about off-anniversary benefit changes, and SBC postcards that are sent to members. Under the ACA both group health plans (customers) and health insurance issuers (health insurers) are required to provide the SBC to participants under certain circumstances.

ACA 60-day notification requirement for off-anniversary benefit changes

For customers who make off-anniversary material modifications (e.g., benefit changes) that affect the content of the SBC, participants in the customer’s group health plan must receive notification of the change (including a new SBC) at least 60 days prior to the effective date. As a result, off-anniversary changes must be submitted to AmeriHealth New Jersey a minimum of 75 days in advance of the effective date to ensure that we can generate the SBC within the required timeframe. All groups are required to adhere to this 60-day notification.

A material modification is a coverage change that would be considered by the average plan participant (member) to be an important change in covered benefits or other terms of coverage, for example, changes to copays, coinsurance, or coverage levels and includes an enhancement as well as a reduction in benefits.

Any customer or health insurer who does not comply with this requirement may be penalized with fines of up to $1,000 for each failure to deliver the SBC to a participant. Note: Each participant would be a separate offense. The penalty may apply to the customer, the health insurer, or both depending on the funding methodology of the customer:

  • Fully-insured customers: The penalty applies to the health insurer and to the group customer.
  • Self-funded customers: The penalty applies only to the group customer.

To ensure compliance of the provisions of the ACA, AmeriHealth New Jersey will implement a new policy which prevents us from releasing a rate quote for a material benefit change within a 60-day period prior to the effective date. ROAM will also be updated in the coming months so that you may only submit a material benefit change 75 days or more prior to the requested off-anniversary effective date.

SBC Postcards

If a customer is not making changes to their benefits from the previous year, AmeriHealth New Jersey will mail a postcard to subscribers (members and any dependents who do not live in the same household as the policy-holder) 30 days prior to their anniversary date. For example, postcards will be mailed on 6/1 for groups with a 7/1 anniversary date. AmeriHealth New Jersey will also mail postcards to all direct bill (individual) members 30 days prior to their anniversary date.

View a sample postcard that we will send to members when their group plan is not making any changes to their benefits. The federal government has suggested certain language to include on the postcard.

If you have any questions about this information, please contact your AmeriHealth New Jersey broker representative.