Summaries based on the original text of the Patient Protection and Affordable Care Act (Passed by the US Senate 12-24-09. Passed by the US House of Representatives 3-21-10. Summary is for informational purposes only. Actual provisions and any amended portions of the bills apply).
Notices and Notice of Modifications to Health Insurance Coverage
No later than 24 months after the date of enactment of the Act health insurance issuers (including a group plan that is not a self insured plan) that offers coverage within the United States; as well as plan sponsors or designated administrators of self-insured plans must provide a summary of benefits in paper or electronic form (pp 26, lines 12-25, pp 27, lines 1-16):
- At the time of application.
- To an enrollee at the time of enrollment.
- To a policy holder or certificate holder at the time of issuance or certificate delivery.
Further, if a health insurer or a group plan makes “material modification to any terms of a plan (that is not already referenced in the summary already provided), that entity must inform enrollees no later than 60 days prior to the effective date of the change (pp 27, lines 17-24, pp 28, lines 1-2).
These standards pre-empt any State standard that provide less comprehensive information to consumers (pp28, lines 3-8).
Violation of these requirements may result in fines of $1000 per offense (pp 28, lines 9 – 14).
Development of Standard Definitions
The Secretary will provide (by regulatory edict) development of the standards for definitions of terms used in health insurance coverage. This will also include insurance related terms and medical terms (pp 28, lines 16-21).
- Some examples of insurance related terms are: premium, deductible, co-insurance, co-payment,, preferred provider, non-preferred provider, out of pocket limit, co=pay, co-payments, UCR (usual, customary and reasonable) fees, grievance and appeals, exclusions – and any other terms the Secretary deems to be relevant in allowing consumers to compare and understand the terms of health insurance coverage. (pp 28, lines 22-25, pp 29, lines 1 – 6).
- The same is true for medical terms such as “…hospitalization, hospital outpatient care, emergency room care, physician services, prescription drug coverage, durable medical equipment, home health care, skilled nursing care, rehabilitation services, hospice services, emergency medical transportation, and such other terms…” Again, such terms are important in defining and comparing medical benefits and exceptions. (pp 29, 7 – 17).