New rules published jointly by the Departments of Health and Human Services, Labor and Treasury, require health insurers and group health plans to provide concise and comprehensible information about health plan benefits and coverage to the millions of Americans with private health coverage. The new rules will also make it easier for people and employers to directly compare one plan to another.
Under the rule, health insurers must provide consumers with clear, consistent and comparable summary information about their health plan benefits and coverage. The new explanations, will be available beginning, or soon after, September 23, 2012. Specifically, these rules will ensure consumers have access to two key documents that will help them understand and evaluate their health insurance choices:
- A short, easy-to-understand Summary of Benefits and Coverage ( or “SBC”); and
- A uniform glossary of terms commonly used in health insurance coverage, such as “deductible” and “co-payment.”
All health plans and insurers will provide an SBC to shoppers and enrollees at important points in the enrollment process, such as upon application and at renewal. A key feature of the SBC is a new, standardized plan comparison tool called “coverage examples,” similar to the Nutrition Facts label required for packaged foods. The coverage examples will illustrate sample medical situations and describe how much coverage the plan would provide in an event such as having a baby (normal delivery) or managing Type II diabetes (routine maintenance, well-controlled).
The rule expands the definition of medical necessity in the glossary beyond “illness, injury, and disease” to also include “conditions.” This is critical to ensuring compliance with the intent of the Americans with Disabilities Act for individuals with physical and mental disabilities. However, the SBC adopts language access standards from an earlier rule governing notices for appeals. Some argue, including the National Health Law Program (NHeLP) that those standards do not comply with the Affordable Care Act’s requirements to provide the SBC (as well as appeals’ notices) in a manner that is culturally and linguistically appropriate and would leave English proficient individuals without assistance.
View the template for the Summary of Benefits and Coverage and the Glossary here.
To view the Final Rule, go here
For more information on the rules announced today, visit www.healthcare.gov
Review the Glossary of Health Coverage and Medical Terms click here.