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2019 ACA compliance overview — SBC and HIPAA

The Affordable Care Act has made significant changes to group health plans since it was enacted in 2010. Many of these key reforms became effective in 2014 and 2015, including health plan design changes, increased wellness program incentives and employer shared responsibility penalties.



Changes to some ACA requirements, such as increased dollar limits, take effect in 2019 for employers sponsoring group health plans. To prepare for 2019, employers should review upcoming requirements and develop a compliance strategy.



This article provides an overview of requirements for Summary of Benefits and Coverage and Health Insurance Portability and Accountability Act certification documents.




Summary of Benefits and Coverage


Health plans and health insurance issuers must provide an SBC to applicants and enrollees to help them understand their coverage and make coverage decisions. Plans and issuers must provide the SBC to participants and beneficiaries who enroll or re-enroll during an open enrollment period, as well as to participants and beneficiaries who enroll other than through an open enrollment period (including individuals who are newly eligible for coverage and special enrollees).



The SBC must follow strict formatting requirements. The federal government provided templates and related materials, including instructions and a uniform glossary of coverage terms, for use by plans and issuers. On April 6, 2016, the Department of Labor issued a new template and related materials for the SBC, effective for use with respect to open enrollment periods or plan or policy years beginning on or after April 1, 2017.


CHECKLIST: Begin using the new SBC template:



  • Ensure that you are using the appropriate SBC template for the 2019 plan year. 

  • For self-funded plans, the plan administrator is responsible for creating and providing the SBC. For insured plans, the issuer is required to provide the SBC to the plan sponsor. Both the plan and the issuer are obligated to provide the SBC, although this obligation is satisfied for both parties if either one provides the SBC. If you have an insured plan, confirm whether your health insurance issuer will assume responsibility for providing the SBCs. 





HIPAA Certification


The ACA includes a requirement for health plans to file a statement with the U.S. Department of Health and Human Services certifying their compliance with the HIPAA electronic transaction standards and operating rules. These HIPAA requirements are often referred to as the electronic data interchange rules.



However, on Oct. 4, 2017, HHS withdrew its proposed rule in order to re-examine the issues and explore options and alternatives to comply with the HIPAA certification requirement. As a result, group health plan sponsors will not be required to certify their HIPAA compliance until HHS issues new guidance.



Although health plans are not required to certify their HIPAA compliance at this time, there is an enforcement process in place for the EDI rules. Civil monetary penalties and criminal penalties may be imposed on a covered entity that fails to comply with the EDI rules. Thus, health plans and business associates that conduct standard transactions should confirm that they are complying with the EDI rules.


CHECKLIST: Analyze your obligations for the HIPAA certification



  • Confirm whether your health plan is complying with any applicable EDI rules. 

  • Work with your advisors to monitor whether HHS issues any additional guidance on the HIPAA certification requirement. 




This summary is a high-level overview of some ACA required documentation. It does not provide an in-depth analysis specific to your organization. If you have any questions or would like to begin talking to an employee benefits consultant, please get in touch by email or by calling (800) 388-1963.

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