Uniform Explanation of Coverage and Coverage Documents
Not less than one year (12 months) after enactment of the Patient Protection and Affordable Health Choices Act, the Secretary will put together standards for insurers for compiling summaries of benefits to insureds.
- The Secretary will work with the National Association of Insurance Commissioners (NAIC), health insurance consumer advocacy organizations, insurers, health care providers (professionals), other qualified persons, patient advocates including those who represent individuals who have a limited proficiency with English in order to create these uniform standards (pp. 23, 6-21).
Some guidelines established for summaries include (pp 24 – 26):
- Appearance – summaries may be no longer than four pages and not include print that is smaller than a 12 point font.
- Language- summaries are to be presented in a “culturally and linguistically appropriate manner” so the summary is understandable to the enrollee.
Contents- Summaries must also include descriptions of:
- Uniform definitions of standard insurance terms.
- “Categories of essential health benefits.”
- Exceptions, reductions or limitations of coverage.
- Cost sharing provisions (deductible, coinsurance limits, co-pays).
- Renewability and coverage continuation provisions.
- A “coverage facts label” that provides illustrations of common benefit scenarios (i.e. such as, pregnancy, serious illness, long term illness and representative cost sharing “scenarios” based on recognized “clinical” practice guidelines.
- A statement of whether or not the coverage meets the standards of minimum “essential coverage.”
- A statement that ensures that the plan or coverage’s share of the total allowed costs be not less than 60% of such costs.
- A statement that the summary is only an outline of coverage and that the actual coverage document should be referenced for information on governing contractual provisions.
- A contract number and a web address for access to an actual copy of the individual policy or group certificate of coverage can be viewed and /or obtained (pp. 26, lines 3-7).
Healthcare Reform 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. This summary is for informational purposes only. Actual provisions and any amended portions of the bills apply).