Non-substantive change justification for SBC Calculator

From: DHHS/CMS/OA/CCIIO/Consumer Support Group

To: Office of Management and Budget

Re: Non-Substantive Change Request for SBC Calculator Update for CMS-10407/OMB Control Number 0938-1146

Date: March 6, 2019

Non-Substantive Change Request to CMS-10407/OMB Control Number 0938-1146

Background

This is a non-substantive change request to CMS-10407 (Summary of Benefits and Coverage, or SBC) to allow CMS to issue a revised version of the SBC Calculator.

The SBC is required under section 2715 of the Public Health Service Act, which was added by the Patient Protection and Affordable Care Act (PPACA). It is a consumer-shopping tool that provides a snapshot of a plan’s benefits, coverage, and any limitations and exceptions. It presents information on a plan’s benefits in a uniform format, which allows for easy comparisons between plans.

One of the sections of the SBC estimates the proportion of costs a patient might pay under a particular plan for three hypothetical medical scenarios (having a baby, treating a foot fracture, and managing well-controlled Type II Diabetes) CMS provides plans and issuers a calculator they can elect to use to calculate the cost-sharing estimates for the three scenarios. The plan or issuer can input a plan’s benefit design and cost-sharing rules for one or more plans into the calculator, and the calculator outputs a summary of cost-sharing estimates for the three coverage example scenarios. The SBC calculator is an optional tool; some plans and issuers may elect to develop their own method for calculating cost-sharing estimates for the medical scenarios. Consumers do not interact with the tool; they only see the calculator’s outputs in the SBC’s coverage examples section.

SBC Calculator Updates

We sought feedback on how the SBC calculator operates from a broad range of both internal and external stakeholders, and made three main types of updates to the calculator: 1) updates to the calculator’s logic to better align with or accommodate how most plans cover benefits; 2) updates to the calculator’s underlying cost data, replacing 2013 Marketscan data with 2016 data; and 3) updates to the calculator’s underlying treatment guidelines. We also corrected minor errors in the previous version of the calculator.

These updates include but are not limited to: adding an emergency department facility fee (correcting an error), adding an additional benefit category for insulin (updates to the underlying treatment guidelines); allowing more flexibility in the way copays, coinsurance and deductibles are applied (updates to the calculator’s logic); and rounding calculator results to be consistent with the SBC Template (correcting an error).

Anticipated Burden Impact

The burden related to the SBC more broadly is included in a separate PRA renewal. We do not anticipate that burden related specifically to this change request will result in a significant change in the burden to plans and issuers. Since issuers that choose to use the SBC calculator are currently using a version of the calculator to input data, and use of the calculator is optional, the burden on plans and issuers will remain largely the same.

Request for Approval

We expect to release the calculator in April of 2019. We therefore request approval of this request prior to 4/15/19. The reason for the urgency of this request is because the updated calculator needs to be released in advance of when plans and issuers populate SBCs so that issuers can get them reviewed by state regulators, and distribute them for the 2020 plan year.