HomeMy WebLinkAboutWellmark-5/4/2015Wellmark®
Wellmark Blue Cross and Blue Shield is an Independent
Licensee of the Blue Cross and Blue Shield Association.
SBC Employer Data Form — Response Required
1. Group Name: City of Waterloo
2. Group Number. XA025
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3. My group is holding an Open Enrollment: 'Yes 0 No
4. If yes, my group's enrollment period is:**
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'• °Enrollment Period' is defined in ACA as the period in which employees can enroll within a plan or plans, and/or when written application materials are provided
to employees, if sooner. t
5. Date SBCs are needed, to include with open enrollment materials:05 / 5, .D15
6. Health Plan Renewal Month (e.g., January): 'JUL.111
7. Plan Year Month (e.g., January): �. OJ U it Oki,-
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8. Group SBC Contact Person Nameftle: JIJI U ,\(',�i1()J l-P,S/ (,�, h_t r) 0_
9. Group SBC Contact Person E-mail: SURU . Selo ircS Ev 14 ty'i (y - ! t7 • b
10. Group SBC Contact Person Phone:
3 - l - S2-1-- Ext:tiniS
11. Group SBC Contact Person Address: 11 G i' wUb etblob gb7D3
Street ° City State Zip
I certify that the above information is accurate and that I am an authorized employee or owner of the employer
withauthority t t n behalf of the employer.
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Employer Sinature
Date
If you will NOT be using standard SBCs provided by Wellmark, please check the option below:
❑ Our Self -Funded group will be developing our own SBCs to distribute.
Please Note: If you modify or opt out of using the standard, Wellmark-provided SBCs, please be aware that
Wellmark will not be able to retain or distribute your customized SBCs to your employees.
Wellmark is not providing, and does not provide, any legal advice with regard to compliance with the requirements of the Affordable Care Act (ACA), or any other
federal or state law This document is not intended, and shall not be construed, to provide any legal advice, and may not be relied upon as such. Regulations and
guidance on specific provisions of the ACA and other federal laws, including but not limited to the transitional reinsurance program fee, have been and will continue
to be provided by the U.S. Department of Health and Human Services (HHS) and/or other agencies. The information provided in this document reflects Wellmark's
understanding of the most current information and is subject to change without further notice. Forspeclfic information regarding the application of these rules to
your facts, or other compliance Issues under applicable law, please consult the advice of your legal advisors.
M-235131 /15
Wellmark
Wellmark Blue Cross and Blue Shield Is an Independent
Licensee of the Blue Cross and Blue Shield Association.
Health Care Reform
Summary of Benefits and Coverage (SBC)
Employer Data Form for Fully Insured Groups 101+ and All Self -Funded Groups
The Affordable Care Act (ACA) requires that all group health plans, group health plan administrators and
health insurance issuers provide a Summary of Benefits and Coverage (SBC) to employees. The SBC is
required to follow a standard format to provide information about coverage and benefits.
Wellmark provides SBCs to Fully Insured 101+ and all Self -Funded employer groups, so that they may
distribute SBCs to employees and COBRA/Continuation beneficiaries as part of open enrollment or renewal,
or in conjunction with the employer's plan year.
Wellmark provides an electronic solution for our Fully Insured 101+ and Self -Funded group customers. SBCs
are emailed* to employer groups. Employers should distribute and/or make SBCs available to employees
during the specific events below. Please be aware that compliance and distribution of SBCs is a Plan
Sponsor responsibility.
1. Open Enrollment Period: All employees must receive SBCs by the first day employees can enroll in a
plan, or when application materials are distributed, if sooner.
2. Auto -Renewing Groups (no Enrollment Period): Self -Funded groups — SBCs must be provided to
employees 30 days prior to renewal. Fully Insured groups — SBCs must be provided to employees no later
than 7 days after issuance of coverage manual.
3. Enrollment: Employees must receive SBCs when s/he changes plans or joins a plan throughout the year
(Le., new hires, special and late entrants).
4. Material Modification (outside of renewal): Updated SBCs must be provided to all employees
60 days in advance of any change that requires the SBC to be changed.
More details on responsibilities concerning SBC applicability and accountability can be found on
WeKnowReform.com.
Next Steps: Please review, complete and return the form on the next page.
To assist Wellmark in providing your SBCs within your compliance period, please provide/update the
information on the next page, verified with your signature, and return it to your Wellmark representative
or broker 30 days in advance of the date that you need SBCs. Thank you for your help as we work to
assist you in complying with this ACA provision. If you have any questions, please contact your Wellmark
representative.
Please note: To ensure SBCs are provided to you within the appropriate time, you will need to notify Wellmark of
your final benefit decision(s) a minimum of 10 business days prior to your date of need.
*Our standard approach to complying with the SBC requirement leverages electronic distribution to provide SBCs to employers (where
employers may post electronic SBCs on their websites for employees to have anytime access). Employers using electronic distribution to
provide SBCs to employees should abide by current Department of Labor electronic distribution guidelines. Options are also available to
provide print/paper SBCs.
Note: Wellmark's BluesEnroll system provides access to SBCs for members using the system for self -serve enrollment.
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