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Donald Berwick, M.D.
Centers for Medicare & Medicaid Services
Department of Health and Human Services
Room 445-G
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, DC  20201

RE: CMS-9982-P and CMS-9982-NC

Dear Dr. Berwick:

The National Coalition for Cancer Survivorship (NCCS), a national organization representing survivors of all cancers, appreciates the opportunity to comment on the proposed rule on the Summary of Benefits and Coverage (SBC) and the Uniform Glossary and the accompanying templates, instructions, and related materials.   We commend the regulatory action to develop and implement a method for comparison of coverage options as mandated by Section 2715 of the Patient Protection and Affordable Care Act (ACA). 

We support the fundamental approach taken by the Departments of Health and Human Services, Labor, and Treasury in proposing a standardized and understandable format for presenting information about insurance and health plan options that will permit cancer survivors to compare their coverage choices and make informed decisions about their coverage.  The Departments made a solid decision in accepting the recommendations of the National Association of Insurance Commissioners (NAIC) related to the SBC and glossary.  The NAIC is to be commended in turn for formulating its recommendations through a working group process that sought the input of representatives of health insurance-related consumer advocacy organizations, health insurance issuers, health care professionals, patient advocates including those representing individuals with limited English proficiency, and other qualified individuals.   

Contents of the SBC

The SBC as proposed is a useful document for consumers, and we endorse the inclusion of information about premiums and a reference to internet addresses for additional plan information.  This information, included in the recommendation from NAIC, is not required by statute.   The availability of premium information, combined with the details of plans in the four-page, double-sided document, will permit cancer survivors to draw comparisons among plans and initiate the process of making decisions about plans that are appropriate for their cancer care and survivorship needs.    In the case of self-funded plans, we recommend that the employer and employee shares of the cost of coverage be delineated.  Only with information about employee responsibility will consumers be able to make true cost comparisons across plans. 

Although the four-page document is a critical tool for comparison of plans, additional information available online may be necessary to answer essential questions about specific elements of cancer care coverage.  For that reason, the availability of such online resources should be clearly communicated.

Distribution of the SBC

The requirement for delivery of the SBC no later than 7 days after an application for insurance or other request information is a reasonable standard.  However, we recommend that the Departments consider a requirement that plans or issuers accomplish delivery of the SBC at the time of electronic or online applications or requests for information.  At a time when consumers increasingly rely on electronic means of communication but at the same time a significant portion of the population does not have reliable access to the internet, we recommend that multiple means of distribution of the SBC be required.  
 
Coverage Examples

We are gratified that the Departments have included breast cancer treatment as one of the three SBC coverage examples.  This example will be useful to those breast cancer survivors who may be making insurance coverage decisions, but more importantly it will serve the purpose of educating other consumers – including those who may be at increased risk of a breast cancer diagnosis -- of the complexity and expense associated with breast cancer treatment, what plans will cover, what they will not, and the cost-sharing responsibilities of patients. 

We encourage the Departments to include as sample care costs in the breast cancer coverage example the costs associated with cancer care planning and coordination.  This service is increasingly considered the standard of care for cancer patients and represents an effective means of boosting cancer care quality and coordinating the multi-disciplinary elements of cancer care.  Inclusion of this sample care costs in the breast cancer example will prompt consumers to evaluate plans for their commitment to care that is coordinated and of high quality.

Glossary

We support the NAIC recommendations regarding the uniform glossary but recommend additions to the glossary.  The glossary entries that we propose will assist cancer survivors and others with serious and life-threatening illnesses evaluate their coverage options. 

The following terms should be added to the glossary:

• Specialty drugs
• Preexisting Condition
• Preexisting Condition Exclusion Period
• External Review
• Clinical Trials – routine patient care costs

Require All Plans to Provide the SBC

All health plans and insurance issuers should be required to provide the SBC.  Although there is a cost associated with the development and dissemination of the SBC, the cost is modest even when considered system-wide and is only a fraction of a dollar when considered on the basis of a covered life. 

Plans that are regulated under the terms of the Employee Retirement and Income Security Act (ERISA) must provide a summary plan document (SPD) that describes covered benefits and enrollee rights and responsibilities.  However, the SPD does not fulfill the goals of the SBC because it is not structured in the way that the SBC will be and therefore prohibits comparison across plans.  It is also not unusual to confront an SPD that is lengthy, complex, and written at high school reading level or above – in other words, these document s are not readily accessible to the average consumer.  As a result, ERISA plans should meet the requirement of providing an SBC. 

Effective Date

The SBC requirement be imposed on March 23, 2012, as required in the statute and specified in the proposed rule.  The changes in insurance marketing practices that will result from the availability of SBC documents should occur as soon as possible, which argues against a delay in the effective date of the requirement.

Thank you again for the opportunity to comment on the SBC and uniform glossary.