NOTE: Requirements for use of the standardized SB apply to all Medicare+Choice (M+C) organizations, 1876 cost contractors, and certain managed care demonstration projects. Demonstration projects required to use the SB include: DoD Subvention, Medicare Choices, SHMO, EverCare, and dual eligible demonstrations, with certain exceptions. For purposes of simplicity, the term M+CO contractor or organization is used throughout the document.

The Balanced Budget Act of 1997 establishes new use of terms used in the past. Of particular concern with regard to avoiding confusion is the term "plan." The term "plan" now refers to the benefit package offered by a M+CO contractor. Please be aware of this change when reading this document.

BACKGROUND

The SB document is the primary pre-enrollment document used by M+COs to inform potential members of their plans' benefit packages. 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 have ranged from a simple benefit comparison matrix to sophisticated documents resembling member handbooks with a foldout benefit comparison matrix. In addition, each M+CO has been 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 has 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, beginning with the annual election period for contract year 2000, the Health Care Financing Administration (HCFA) will require M+COs participating in the M+C program to use a standardized SB. As with our other efforts to assist beneficiaries in making more informed health care decisions, we will assess the usefulness of the SB in order to improve it if necessary.

The standardized SB is a stand-alone marketing document that is based on a universal, menu- driven template which allows the M+COs to choose those items that are applicable to their plans from a selection (menu) of responses designed to cover all operational possibilities. 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 (2 to 4 pages, limited to 1-2 pages of promotional text, free format and text.)

HCFA POLICY DIRECTIVES

1. Federal Pre-Emption of State Regulatory Requirements:

   In order to avoid the possibility of conflicting State and Federal regulatory requirements regarding utilization of the standardized SB, HCFA will use its Federal pre-emption authority. HCFA interprets the M+C regulations to require a standardized format and language for description of benefits; this standardization must be used in order to comply with Federal law. Under longstanding constitutional principles of Federal pre-emption, restated in section 1856(b)(3)(A) with respect to M+C standards specifically, any state law that is inconsistent with Federal requirements is pre-empted.

2. Applicability of the Standardized SB to Employer Groups:

   Enrollees whose source of enrollment is through an employer sponsored group are not currently included in the mandated use of the standardized SB for either annual notification or initial marketing purposes.

3. Value Added Services (VAS):

   HCFA continues to work towards a VAS policy with other Federal regulatory agencies whose statutory authority and program activities impact the M+C program. Until further notice, contracting M+COs must follow the VAS guideline provided on page 11 of the Medicare Managed Care National Marketing Guide. VAS are not included in the M+CO's HCFA-approved (ACR) benefit package, cannot be offered in pre-enrollment marketing materials and, therefore, cannot be included in the SB benefit comparison matrix.

TECHNICAL DIRECTIVES

1. In selecting your benefit responses from the SB template, be sure to consider the operational characteristics of your plan; open or closed access, M+CO contractor type, etc.

2. It is acceptable to print the SB in either portrait or landscape page format.

3. 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.

4. Printing font size of 12 or larger must be used for the SB (including footnotes).

5. Copayments and/or deductibles that vary within a specific benefit category must be listed individually for each item (e.g., copayments for prescription drugs should be listed separately based on the drug being a brand name, generic, mail order drug, etc.).

6. More than one response may be required for a specific benefit category. Be sure to include all descriptive items that apply to the plan for each benefit category.

7. In the benefit comparison matrix, items that are within parentheses and in italics are instructions; items within brackets are optional choices.

8. 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.

9. 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 III (M+CO special features) of the SB. An M+CO must include a brief description of optional supplemental benefits in section III of the SB, the additional premium/copay requirements for the optional supplemental benefits must also be shown.

10. The health plan column of the comparison matrix often provides an option of indicating copayments or other beneficiary out-of-pocket expenses as either a dollar ($) amount or a percent (%) amount. The percent (%) amount refers to the percent of the total amount charged for the service.

11. The title "Summary of Benefits" must appear on the cover page of the document.

1. The Beneficiary Information Section
   1. This section is to be incorporated into your SB exactly as shown in the template document. 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 accurately represent the entire service area for which the SB is applicable.

   2. The third paragraph on page 1, fourth sentence, indicates in brackets (i.e., optional) that "We also offer additional benefits, which may change from year to year". If your M+CO offers additional, optional, or mandatory supplemental benefits, this statement is mandatory, not optional.

   3. The last sentence in the enclosure box on page 2 indicates that "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. Compliance with these requirements meet the intent of the above SB sentence. No additional new requirements are imposed by the above SB reference.

2. Benefit Comparison Matrix Instructions:

   NOTE: Most items in the SB comparison matrix are self-explanatory. When using the SB benefit matrix template, pay close attention to internal instructions contained within the matrix categories. Items that are self-explanatory will not be included in these instructions. Remember, the structure, format, and descriptive language contained in the SB benefit matrix template are mandatory. Except for benefits described in the plan specific special features section and not covered in the benefit template, you must use the standardized SB as provided by HCFA.

   Premium: (Plan Description)

   You should express your monthly plan premium as a dollar amount.

   Doctor Office Visits: (Plan Description)

   This category may have more than one response; be sure to include all appropriate descriptive items for your plan.

   Emergency and Urgently Needed Care: (Plan Description)

   Be sure to indicate if this benefit for your M+CO is "world-wide" or limited to the U.S., and certain locations in Canada and Mexico.

   Manual Manipulation of the Spine (MMS): (Benefit Category)

   NOTE: MMS is listed as the original Medicare benefit rather than Chiropractic Services (CS). Expanded CS benefits, if offered by the M+CO, are listed under the Additional Benefits section of the SB.

   You must indicate the provider type (medical credentials) in the Health Plan column of the person delivering the MMS service (e.g., Doctor of Osteopathy, Doctor of Chiropractory, etc.). You may list the item more than once if you contract with more than one provider type to provide the service and different copayments are required.

   Medically Necessary Foot Care (MNFC): (Benefit Category)

   NOTE: MNFC is listed as the original Medicare benefit rather than Podiatry Services (PS). Expanded PS, if offered by the M+CO, are listed under the Additional Benefits section of the SB.

   You must indicate the provider type (medical credentials) in the Health Plan column. You may list the item more than once if you contract with more than one provider type to provide the service and different copayments are required.

   Inpatient Hospital Care: (Plan Description)

   See instructions in the benefit matrix regarding multiple listings to explain different copayments.

   Skilled Nursing Facility: (Plan Description)

   You must include one of the selections which describes your M+CO's benefit regarding hospital stay requirements prior to qualifying for SNF services. The hospital stay requirement cannot be longer than the original Medicare criteria of 3 days. If your M+CO's benefit is less than 3 days, you must indicate the hospital stay criteria in days.

   Annual Screening Mammograms: (Plan Description)

   You must include one of the "No Referral Necessary" statements in your benefit description.

   Pap Smears and Pelvic Exams: (Plan Description)

   You must include one of the "No Referral Necessary" statements in your benefit description. If a separate office visit charge is associated with the benefit, you must also include this information in the description of the benefit.

   Outpatient Prescription Drugs: (Plan Description)

   If your M+CO has a time limited drug benefit, you must include one of the statements provided which indicates the minimal time period for which the benefit applies (e.g., a $250 quarterly limit with a maximum annual limit of $1,000). If such is the case, you must indicate that unused drug benefits are not carried forward to new benefit periods.

   Dental Services: (Plan Description)

   You must list copayments for at least dental cleanings, x-rays, and oral exams, if applicable. You may list additional dental benefits with copays, or you may use the statement in the matrix "Additional benefits available. Ask [Enter the M+CO Name] for details."

   Hearing Services: (Plan Description)

   This benefit item is complicated. Be sure to use the most descriptive language provided to accurately describe your M+CO's benefit. If necessary, you may further describe the M+CO's hearing benefit in the M+CO special features section of the SB (see detailed instructions below in "Plan Specific Special Features" for expansion of comparison matrix benefits.)

3. Plan Specific Special Features:

   This section is limited to a maximum of four pages (limited to 1-2 pages of promotional text) and is not standardized with regard to format or content, with one exception. M+COs must use this section to briefly describe all optional supplemental benefit offerings and the additional premium/copay that must be paid to receive them. This section is used by the M+COs to describe special features of the M+CO or other items to assist the marketing aspect of the SB; e.g., verbiage, graphics, pictures, maps, etc. may be used in this section. 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 which 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 [xx] 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 [xx] for more information on 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.

Closing Note:

This document 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 document 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 contract manager. You may also post your questions through the Internet by writing to: summaryofbenefits@hcfa.gov Finally, the Summary of Benefits package, along with the "SB Questions and Answers," will be posted to the Internet on June 18 at: www.hcfa.gov/medicare/sum-ben.htm

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Last Updated June 24, 1999