“(2) LANGUAGE.—The standards shall ensure that the summary is presented in a culturally and linguistically appropriate manner and utilizes terminology understandable by the average plan enrollee.
“(3) CONTENTS.—The standards shall ensure that the summary of benefits and coverage includes—
“(A) uniform definitions of standard insurance terms and medical terms (consistent with subsection (g)) so that consumers may compare health insurance coverage and understand the terms of coverage (or exception to such coverage);
“(B) a description of the coverage, including cost sharing for—
“(i) each of the categories of the essential health benefits described in subparagraphs (A) through (J) of section 1302(b)(1) of the Patient Protection and Affordable Care Act; and
“(ii) other benefits, as identified by the Secretary
“(C) the exceptions, reductions, and limitations on coverage;
“(D) the cost-sharing provisions, including deductible, coinsurance, and co-payment obligations;
“(E) the renewability and continuation of coverage provisions;
‘‘(F) a coverage facts label that includes examples to illustrate common benefits scenarios, including pregnancy and serious or chronic medical conditions and related cost sharing, such scenarios to be based on recognized clinical practice guidelines .
“(I) a contact number for the consumer to call with additional questions and an Internet web address where a copy of the actual individual coverage policy or group certificate of coverage can be reviewed and obtained .
The new law required Secretary of Health and Human Services Kathleen Sebelius to consult with state insurance commissioners, insurance companies, patient advocates and even “those representing individuals with limited English proficiency” to come up with the template for this revolutionary four-page document—which she did.
Her template, which became six pages including “coverage examples” and frequently asked questions, can be found here [PDF], and it’s an extraordinary step forward. (Indeed, a camera shot of one of its pages, with a brief narrative explanation from the president, would make for a better Obama reelection TV ad than anything I’ve seen from his campaign so far.)
It would be great to see a story on how the template was put together, what the potential weaknesses are and, most important, how insurance companies are working to comply with, or find loopholes in, its mandates by September, when they have to fill it in with their own language summarizing their own plans.
The law stipulates a fine of $1,000 per insurance customer for each time someone is not given an adequate document. Editors ought to be assigning stories now on how that’s going to be enforced.
Insurance companies and group health plans must also provide 60 days’ notice whenever any of the provisions in their plans, as summarized in the new document, are about to be changed. That sounds like good protection for patients, but it prompts a final question: I don’t see anything in the statute prohibiting insurance companies from changing their plans midstream - say, by deciding to disallow some drug or not to cover some procedure it had been covering.
I’ve always wondered about that, because if an insurance plan is a contract - I agree to pay the company, and it agrees to provide certain coverage - how can the company change the deal before the contract ends? What are the rules, if any, about that?
Appealing rejected claims
There are all kinds of other provisions in Obamacare that are equally important, some of which have supposedly already been implemented, but that also seem to have eluded the press.
Another example: There’s a provision guaranteeing as of last January that a patient denied coverage by his insurance carrier not only can appeal to the insurance company (which must respond within specific deadlines) but also has the right, as the law puts it, to an “effective external review process that meets minimum standards established by the Secretary.” What does that mean, and how is it being implemented? Our family recently contested a rejected claim and we were not told of any right to appeal to an outside, independent party. If this requirement has not been implemented, that’s a great story, too.
Obamacare will have sweeping effects on a larger sector of our economy and a broader swathe of our population than any law in recent history. It’s time to switch from solely focusing on the political and legal battles surrounding it to how it’s actually working and going to work.