§300gg–15 Development and Utilization of Uniform Explanation of Coverage Documents and Standardized Definitions

Summary

Requires the Secretary of Health and Human Services to create rules (within 12 months after March 23, 2010) for a short, plain Summary of Benefits and Coverage that health plans and insurers must use. The summary must be uniform, no more than 4 pages, in at least 12-point type, and written in language people can understand. It must include standard definitions, a description of what the plan covers (including the 10 essential health benefit categories and any other benefits the Secretary requires), exceptions and limits, cost-sharing details like deductible, coinsurance, and copays, rules about renewing or continuing coverage, a “coverage facts” label with example scenarios (for things like pregnancy and serious or chronic conditions), a statement about whether the plan meets minimum essential coverage and pays at least 60% of allowed costs, a note that the summary is only a summary and the full policy controls, and a phone number and website to get the full policy. The Secretary must consult insurers, the NAIC, consumer and patient groups, medical experts, and others when making the rules and must review them over time. Within 24 months after March 23, 2010, insurers and self-insured plan sponsors must give the summary to applicants at application, to enrollees before enrollment or reenrollment, and to policyholders when the policy or certificate is issued. Paper or electronic copies are allowed. If a plan makes a material change not shown in the most recent summary, it must tell enrollees at least 60 days before the change. Federal rules override state rules that give consumers less information. A willful failure to provide the summary can bring a fine of up to $1,000 per violation per enrollee. The Secretary must also set standard definitions for insurance terms (for example: premium, deductible, coinsurance, copayment, out-of-pocket limit, preferred/non-preferred provider, out-of-network copays, UCR fees, excluded services, grievance and appeals) and for medical terms (for example: hospitalization, hospital outpatient care, emergency room care, physician services, prescription drugs, durable medical equipment, home health care, skilled nursing care, rehabilitation, hospice, and emergency medical transportation).