NOTE: Requirements for use of the standardized SB apply to all Medicare+Choice organizations (M+COs), 1876 cost contractors, and certain managed care demonstration projects, including Medicare Choices, EverCare, DoD Subvention and SHMOs. The general instructions provided below apply to all of these entities. HCFA has developed additional instructions for cost contractors, which are posted on the HCFA web site at: www.hcfa.gov/medicare/2001_qa.htm. A series of Questions and Answers is also provided at this site. M+COs, cost contractors, and the demonstration projects mentioned above are strongly encouraged to review these Questions and Answers and to post any additional questions through the Internet to: summaryofbenefits@hcfa.gov. Since HCFA will post answers to these questions on the web site at regular intervals, M+COs, cost contractors and the demonstration projects mentioned above are strongly encouraged to review the web site regularly for updates.

M+COs and contracting health plans should also review the package of materials that describes contract refinements for CY 2001, which is also available on the HCFA web site. These materials include Operational Policy Letter 2000.121, which provides specific instructions for renewing plans, as well as the revised National Marketing Guide.

For purposes of simplicity, the term M+CO contractor or organization is used throughout the document. The term "plan" now refers to the benefit package offered by an M+CO contractor. Please be aware of this change when reading this document. M+COs and contracting health plans should also review the separate package of materials for renewing plans, which is also available at the HCFA web site.

The SB document is the primary pre-enrollment document used by M+COs to inform potential members of the plan benefit packages offered by M+COs. Similarly, Medicare beneficiaries have indicated the SB is the single most important document produced by the M+COs that assists the beneficiary in making a health care selection.

M+COs participating in the M+C program often provide a side-by-side comparison of plan benefits to the original Medicare fee-for-service benefit package so the potential member can visualize the benefit enhancements the M+CO offers beyond the original Medicare program. In the past, M+COs’ SBs ranged from a simple benefit comparison matrix to sophisticated documents resembling member handbooks with a foldout benefit comparison matrix. In addition, each M+CO was allowed to use its own structure, format, and descriptive language in providing benefit information to prospective Medicare beneficiary members. Such a wide variety of documents caused confusion and difficulty regarding beneficiary comparison shopping for the plan best suited to meet the individual beneficiary’s health care needs. For these reasons and others, the Health Care Financing Administration (HCFA) required M+COs participating in the M+C program to use a standardized SB beginning with the annual election period for Contract Year (CY) 2000.

The standardized SB is a stand-alone marketing document that is based on a report generated from the Plan Benefit Package (PBP) describing plans’ benefits and costs. The SB contains three sections: (1) the beneficiary information section, designed to inform potential members of important aspects of participating in the M+C program (two pages, standard format, and text); (2) the benefit comparison matrix section (approximately 10 pages, standard format and text); and (3) the M+CO special features section (4 pages of promotional text and graphics; free format and text.) The SB is a "summary" document and therefore not intended to include benefit information to the same degree as the Evidence of Coverage. The SB and Medicare Health Plan Compare will contain the same information in the same format for CY 2001.

In the past, HCFA reviewed SBs to ensure that the information provided matched the information provided in the Benefit Information File (BIF), which was submitted with each plan’s Adjusted Community Rate (ACR) Proposal. For CY 2001, the new PBP will replace the BIF and include much more information about each M+CO’s benefit packages. In addition, Sections 1 and 2 of the 2001 SB have been integrated into the PBP and will be generated as output reports from the PBP. These sections will be generated in similar format and with similar language as required in the standardized SB for CY 2000, but will also include some changes based on comments from the managed care industry, Medicare beneficiaries, and other interested parties. M+COs should generate Sections 1 and 2 from their completed PBP, download these sections into the appropriate publishing software, and combine them with Section 3 to form a complete SB. M+COs may make only the necessary modifications permitted by HCFA (described below) and must then submit the SB to HCFA for review.

1. Federal Pre-Emption of State Regulatory Requirements:

2. Applicability of the Standardized SB to Employer Groups:

3. Value-Added Items and Services:

M+COs should first carefully review the separate instructions for completing the PBP and related Questions and Answers (also available at http://www.hcfa.gov/medicare/2001_qa.htm) and complete their PBP before producing Sections 1 and 2 of the standardized SB. M+COs should print a copy of Sections 1 and 2 before submitting their PBP and carefully review these sections before submitting their PBP by July 3rd. HCFA reviewers will have the ability to generate Sections 1 and 2 from the M+CO’s PBP and will compare these sections to those submitted as part of the M+CO’s entire SB. Any discrepancies between the sections submitted by the M+CO and those produced by HCFA that are not described below must be corrected before the SB will be approved by HCFA.

1. M+COs must adhere to the language and format of the standardized SB and are only permitted to make the changes outlined below in these instructions. Changes to the language and format of the SB template will result in disapproval of the document and will delay approval of the SB.
   
   
2. The title "Summary of Benefits" must appear on the cover page of the document.
   
   
3. All three sections of the SB must be provided together as one document and may not be bound separately or placed in a folder in separate sections. M+COs may describe several plans in the same SB package and bind these descriptions together, but may not include any additional information in the bound package. For example, an M+CO may produce a package that includes one Section 1, multiple Section 2s for several plans and, if applicable, multiple section 3s for these plans. These sections can then be bound together, but cannot include any other information. Additional materials can be mailed with the SB (see instruction #13 below), but cannot be bound with Sections 1, 2 and 3 of the SB.
   
   
4. Front and back cover pages are acceptable.
   
   
5. Printing font size of 12 point or larger must be used for the SB (including footnotes). (Since Sections 1 and 2 will not be generated from the PBP in 12-point font, the M+CO should change the font to ensure that the font size is 12 point.) M+COs may enlarge the font size and also use bolded or capitalized text to aid readability, provided that these changes do not steer beneficiaries to or away from any benefit items or interfere with the legibility of the document.
   
   
6. Colors and shading techniques, while permitted, must not direct a beneficiary to or away from any benefit items and must not interfere with the legibility of the document. There is no requirement regarding the type of paper used.
   
   
7. M+COs may include their phone number at the bottom of each page of the SB. Each time the M+CO’s phone number appears in the SB, the M+CO’s TDD or TTY number must appear after it.
   
   
8. It is acceptable to print the SB in either portrait or landscape page format.
   
   
9. It is acceptable for M+COs with multiple plans (separate ACRs) to include more than one plan in the side-by-side benefit comparison matrix. However, since the PBP will only print the Section 1 and 2 reports for one plan, the M+COs will have to create a side-by-side comparison matrix for two plans by manually combining the information into a chart format. If the SB only includes one of several plans offered, the availability of other plans must be noted in the Annual Notice of Change (ANOC) letter. (A model ANOC letter is provided in OPL 2000.121, also available on HCFA’s web site.)
   
   
10. If an M+CO wants to include mandatory supplemental benefits beyond those benefits found in the comparison matrix, the M+CO must place the information in Section 3 (M+CO special features) of the SB. An M+CO must include a brief description of the benefits and any associated premium/copay requirements. These instructions are also applicable for optional supplemental benefits should the M+CO elect to include any in the SB.
    
    
11. If an M+CO includes additional information about covered benefits in Section 3, the M+CO may include a page reference to this information in the appropriate box in the comparison matrix in Section 2, i.e., See page ___ for additional information about this benefit.
    
    
12. M+COs may include additional information about covered benefits in a separate flyer or other material and mail this with the standardized SB and the Annual Notice of Change Letter.

1. This section is to be incorporated into your SB exactly as it is generated by the PBP. Note that M+COs have the option of indicating at the top of this section a geographic name, e.g., "Southern Florida." If used, the geographic name must match the geographic label indicated in the Health Plan Management System (HPMS).
   
   
2. Section 1, as generated by the PBP, will include the applicable H number and plan number at the top of the document. M+COs must delete this information.
   
   
3. The fourth paragraph contains a sentence, "We also offer additional benefits, which may change from year to year." If this is not applicable to your plan, you must remove this sentence.
   
   
4. Note that the second Question and Answer in Section 1 includes the plan’s service area; the PBP will generate a list of counties, with an * indicating those counties that are partial counties. The M+CO may list the zip codes of these counties in this section or provide a cross reference to Section 3 and list the zip codes here. The M+CO must also explain in Section 1 that the * indicates a partial county.
   
   
5. The second Question and Answer in Section 1 lists the plan’s service area, but does not indicate that the information listed represents counties. Therefore, the M+CO must amend its SB so that the answer reads, "The service area for this plan includes the following counties: [list of counties automatically generated by the PBP].
   
   
6. The description of the plan’s service area, as generated from the PBP, will include the state abbreviation after each county. The M+CO must eliminate the state abbreviation after each county listed.
   
   
7. The fourth Question and Answer in Section 1 indicates whether or not the plan covers services received outside of the network. If the M+CO is designated as an HMO POS, then the sentence will indicate that the member can go to any doctor outside of the plan’s network. However, this sentence may not accurately describe the plan’s POS benefit. M+COs must delete the first sentence of the paragraph ("You can always choose to go to a doctor outside our network."). You must not change any of the remaining text, which is designed to alert the beneficiary that accessing services outside the M+CO’s provider network is possible but the beneficiary should contact the M+CO and/or see a specific page in section 3 of the SB for more information. (You may also add the following sentence: "See page __ for more information.")
   
   
8. The last sentence in the enclosure box on page 2 indicates, "If you have special needs, this Summary of Benefits may be available in other versions." M+COs contracting with HCFA are obligated to follow the regulatory requirements of the Americans with Disabilities Act and the Civil Rights Act of 1964. Compliance with these requirements satisfies the intent of the above SB sentence. No additional new requirements are imposed by the above SB reference.
   
   
9. The software patch now available on HPMS will now generate three new sentences at the end of the section instructing members to contact Medicare or the plan for more information. M+COs should enter the appropriate phone numbers where placeholders are provided, since these data are not collected in the PBP. (Please see separate instructions for the software patch, which are also available on the HCFA web site.)

NOTE: The SB comparison matrix will be generated by the PBP in a chart format with the required language. Therefore, the information included in the PBP must first be correct in order for the SB comparison matrix to also be correct. M+COs should review the comparison matrix to ensure that all of the information presented is correct. Information presented in the comparison matrix must match the information presented in the PBP, with the exception of the permitted and/or necessary changes discussed below. If any changes are required, the M+CO must make these changes in the PBP prior to the July 3^rd deadline for submission of ACR/PBP, generate a revised SB benefit matrix, and include this matrix in its SB. HCFA reviewers will have with the benefit comparison matrix that is generated by the PBP and will compare this with the matrix provided as part of the plan’s SB. Any discrepancies between the matrix generated by HCFA and that provided by the plan (with the exception of those permitted below) will result in disapproval of the SB.

If the M+CO offers benefits that are not fully described in the comparison matrix, the M+CO may include this information in Section 3, discussed below. The M+CO may not change or amend the language in the comparison matrix unless as provided below.

1. The comparison matrix generated by the PBP will not contain the required footnotes. Therefore, the M+CO must include the following footnotes provided below. Please note that the footnote number must appear in the text of the column and the footnote must appear at the bottom of each page. Please note: For review purposes, the M+CO can list all of the footnotes at the end of Section 2, but the final proof copy must include the footnotes at the appropriate points in the text. If the M+CO chooses this option, the M+CO must notify the HCFA Regional Office conducting the review and must indicate in the SB where the footnotes will actually appear in the final printed version.
   
   
   • (1) Each year, you pay a total of one $100 deductible.

     This footnote must be referenced after every statement in the Original Medicare (OM) column that describes the required Medicare coinsurance, i.e., "You pay 20% of Medicare approved amounts." This footnote must also appear at the bottom of each page that contains this statement. This statement is contained in the OM column describing the following benefits:

     • Doctor Office Visits
     • Outpatient Mental Health Care
     • Outpatient Substance Abuse Care
     • Outpatient Surgery (both statements must be footnoted)
     • Emergency Care (both statements must be footnoted)
     • Urgently Needed Care
     • Ambulance Services
     • Durable Medical Equipment
     • Prosthetic Devices and Medical Supplies
     • Diagnostic Tests, X-Rays, and Lab Services (only the first statement)
     • Radiation Therapy
     • Manual Manipulation of the Spine
     • Medically Necessary Foot Care
     • Outpatient Rehabilitation Services
     • Mammograms/Pelvic Exams
     • Bone Mass Measurement
     • Colorectal Screening Exams
     • Prostate Cancer Screening Exams
     • Diabetes Monitoring
     • Hepatitis B Vaccine
     • Vision Services (only the first second statement)
     • Hearing Services (only for the statement regarding diagnostic hearing exams).
   • If your doctor does not participate in the Medicare program, you pay any charges up to 115% of the Medicare approved amount.
   • (2) If a doctor or supplier chooses not to accept assignment, their costs are often higher, which means you pay more.

     This footnote must be referenced after every statement in the OM column that describes the following benefits and after footnote (1), where applicable. The text of this footnote must appear at the bottom of each page that contains this statement. This statement is contained in the OM column describing the following benefits:

     • Doctor Office Visits
     • Outpatient Mental Health Care
     • Outpatient Substance Abuse Care
     • Outpatient Surgery (both statements must be footnoted)
     • Emergency Care (both statements must be footnoted)
     • Urgently Needed Care
     • Diagnostic Tests, X-Rays, and Lab Services (both statements must be footnoted)
     • Radiation Therapy
     • Manual Manipulation of the Spine
     • Medically Necessary Foot Care
     • Outpatient Rehabilitation Services
     • Mammograms/Pelvic Exams
     • Bone Mass Measurement
     • Colorectal Screening Exams
     • Prostate Cancer Screening Exams
     • Diabetes Monitoring
     • Vision Services (only the first statement)
     • Hearing Services (only for the statement regarding diagnostic hearing exams).
   • A benefit period begins on the first day of admission to a hospital and ends when you have been out of the hospital or other facility primarily providing skilled nursing or rehabilitation services for 60 days in a row. Benefit periods are renewable.
   • (3) A benefit period begins the day you go to a hospital or skilled nursing facility. The benefit period ends when you have not received hospital or skilled nursing care for 60 days in a row. If you go into the hospital after one benefit period has ended, a new benefit period begins. You must pay the inpatient hospital deductible for each benefit period. There is no limit to the number of benefit periods you can have.

     This footnote must be referenced after the words "benefit period" in the OM column describing Inpatient Hospital Care and Skilled Nursing Facility and the text of this footnote must appear at the bottom of the page on which these benefits are described.

   • (4) Lifetime reserve days can only be used once.

     This footnote must be referenced after the statement, "Days 91-150: $338 each lifetime reserve days" in the OM column describing Inpatient Hospital Care. The text of this footnote must appear at the bottom of the page on which these benefits are described.

2. M+COs that waive the co-pay for Emergency Care if the member is admitted to the hospital within a specified number of days or hours for the same condition will need to must describe this policy in the PBP and then add the following sentence:

   "You do not pay this amount if you are admitted to the hospital within [insert number of days or hours, whichever is applicable] for the same condition."

   This sentence should follow the first sentence that appears: "You pay [amount] for each Medicare-covered emergency room visit." No additional changes to this language are permitted.

3. For the Inpatient Hospital category, the SB sentences generated by the PBP do not describe any limits on the member’s out-of-pocket costs. Therefore, if the M+CO limits the member’s out-of-pocket costs to a specified amount, the M+CO must insert the following sentence:

   "Your out-of-pocket costs may be limited."

   The M+CO may then describe any limits on the member’s out-of-pocket costs in Section 3 and provide the appropriate cross reference in the matrix by inserting the sentence, "Please see page __ for more information."

4. With respect to the Hospice category, the M+CO may must replace the sentence that is automatically generated, "Information Not Available" and either 1) insert the following sentence:

   "You may receive care from any Medicare-certified hospice." This plan does not cover hospice services.";

   M+CO that offer hospice care may Or 2) include any additional information about the plan’s hospice benefits in Section 3 and reference this information in the plan column of the Hospice category as follows:

   "See page ___ for information about this benefit."

5. The following sentence automatically appears in the plan column of the Diabetes Monitoring category:

   "Contact [plan] to determine if the above applies to your prescription drug benefit."

   This will appear even if the M+CO indicates in the PBP that there is no drug benefit beyond Original Medicare. This statement is incorrect, since the Diabetes Monitoring category does not include prescription drugs. Therefore, M+COs can must remove this sentence delete the entire sentence from their SB if this is not applicable, but should be sure to indicate in their PBP that there is no drug benefit beyond Original Medicare.

6. In the "Annual Screening Mammograms" category, the sentence, "No referral necessary for network providers" does not appear. M+COs must insert this sentence in the plan column of their matrix.
   
   
7. In the Dental benefit category, the following sentences appear even if the plan does not offer additional benefits beyond preventive dental benefits:

   "Additional benefits available. Ask [name of plan] for details."

   M+COs must delete these sentences in the plan column of the SB matrix if they are not applicable.

8. In the Hearing category, the sentence, "You pay 100% for hearing aids" appears in the plan column of the matrix even if the plan offers a hearing aids benefit. M+COs must delete this sentence in the plan column if it is not applicable.
   
   
9. In the Outpatient Prescription Drug column of the matrix, the following sentences appear even when the plan does not offer prescription drugs or offers drugs but does not impose dollar limits on prescription drugs:

   "Plans can calculate the part you pay in different ways. Please ask [name of plan] about how we determine drug costs that count towards these limits."

   M+COs must delete this sentence if they do not offer prescription drug coverage, or if they offer drugs but do not impose dollar limits on prescription drugs.

10. For several additional benefit categories (Acupuncture, Chiropractic Services, Health/Wellness Education, Podiatry Services, and Transportation) the column appears blank if the M+CO does not offer these services as additional or mandatory supplemental benefits. Therefore, the M+CO must insert the sentence, "In general, you pay 100%" in the plan column of Section 2 for the Chiropractic Services, Podiatry Services, and Transportation categories if the M+CO does not offer these services as additional or mandatory supplemental benefits. The Original Medicare column for these categories will be revised to include this language. This language has been revised in both columns to ensure that beneficiaries are aware that there are related Medicare-covered benefits in each of these categories.

    With respect to the Acupuncture and Health/Wellness Education categories, the M+CO must insert the sentence, "You pay 100%" if the M+CO does not offer these services as additional or mandatory supplemental benefits. The Original Medicare column currently includes this language for these categories.

    Note: If the M+CO offers any of these benefits as optional supplemental benefits and describes these benefits in Section 3 of their SB, then the M+CO must also insert the sentence, "See page ___ for more information about this benefit" in the plan column of Section 2 for each benefit offered. This sentence would include the appropriate page reference in Section 3 where the description of this benefit could be found.

11. Different section headings (e.g., "Important Information," "Summary of Benefits" and "Outpatient Medical Services and Supplies" appear in a separate column on the far left-hand side of the grid. The M+CO can center the headings over the appropriate section in the matrix and bold the text.
    
    
12. The following sentence automatically appears in the plan column of the Dental, Vision, and Hearing benefit categories for M+COs offering a POS benefit:

    "You may use any provider."

    To more fully describe the plan’s rules regarding the use of providers for these benefits, M+COs may add the following sentence: "See page __ for additional information about this benefit."

13. For the Outpatient Drugs category, the PBP does not generate a cost share and day supply sentence for the Formulary Preferred Drugs offered in a Designated Retail Pharmacy if the M+CO offers this individual drug type. Therefore, if the M+CO offers Formulary Preferred Brand drugs in a Designated Retail Pharmacy for a copayment up to a specified day supply, then the M+CO must add the sentence “ $__ for preferred brand name drugs up to a __ day supply” and insert the appropriate copayment amount and day supply information as entered in the PBP.
    
    
14. In the Skilled Nursing Facility category, the sentence, “There is a limit of 100 days each benefit period,” is not generated in the SB if the M+CO does not select Additional Days as an Additional or Mandatory Supplemental benefit. Therefore, if the M+CO does not offer additional days as an Additional or Manadatory Supplemental benefit, then the M+CO must insert the sentence, “There is a limit of 100 days each benefit period” in the plan column of Section 2.
    
    
15. In the Outpatient Prescription Drug category, the phrase, “Note about dollar limits” appears even if the plan does not have dollar limits. All M+COs must delete this sentence, regardless of whether or not they have dollar limits on prescription drugs.
    
    
16. In the Dental Benefits category, the sentence, “You must use network providers” appears even if the plan does not offer additional or mandatory supplemental benefits in this category. Therefore, M+COs that do not offer additional or mandatory supplemental benefits in this category must delete this sentence.
    
    
17. In the Inpatient Mental Health Category, the following sentence should be automatically generated for all Part A/B plans:

    Calendar year benefit limited by prior partial or complete use of 190-day lifetime treatment in a psychiatric hospital. (If your benefit does NOT have such a limitation, then the Minimum number of benefit days in the calendar year must be 190 days.)

    If this sentence does not appear in the SB as generated from the PBP, then the M+CO must manually insert this language in their SB.

This section is limited to a maximum of four (4) pages of promotional text and graphics and is not standardized with regard to format or content. Section 3 is used by the M+CO to describe special features of the M+CO beyond information contained in Sections 1 and 2 of the SB. Section 3 may contain non-standardized language, graphics, pictures, maps, etc.

The 4-page limit means that the information is limited to 4 single-sided pages or 2 double-sided pages. There are no exceptions to this limitation.

If an M+CO elects to display optional supplemental benefits in the SB, they must appear in Section 3. The M+CO must include a brief description and any associated premium/co-pay information for these benefits if the M+CO elects to include them in the SB.

M+COs may use this section for mandatory supplemental benefits that do not appear in the comparison matrix section. If the M+CO chooses to further describe a benefit in this section that appears in the comparison matrix, the M+CO may add a note at the bottom of the box to refer to this section. If the M+CO chooses to do this, the note must say "See page ___ for more information on (Enter the benefit category exactly as it appears in the left column.)." For example, if an M+CO wishes to further describe their dental benefit, in the Health Plan column of the SB, in the row titled Dental Services, they would add a note at the bottom saying "See page ____ for more information about dental services." Use of language regarding superlatives, testimonials, and other marketing statements is governed by the marketing rules found in the Medicare Managed Care National Marketing Guidelines.

This standardized SB is designed to provide the M+CO plan with adequate descriptive information to perform marketing of the M+CO’s plans while at the same time assisting potential Medicare beneficiaries in performing comparison shopping for the health care provider best suited to meet their needs. The standardized SB will also be used to inform existing M+CO members of the benefit changes for the new contract year. Should you require assistance in clarification or use of this document, please contact your HCFA Regional Office Plan Manager. You may also post your questions through the Internet by writing to: summaryofbenefits@hcfa.gov. The "SB Questions and Answers," will be updated regularly and posted on the Internet at: http://www.hcfa.gov/medicare/2001_qa.htm.

Return to CY 2001 ACR/PBP Information

Last Updated July 20, 2000