New rules and standards issued in August under the Patient Protection and Affordable Care Act (PPACA) are intended to help plan participants “easily understand their health coverage and determine the best health insurance options for themselves and their families.”

The regulations, which take effect March 23, 2012, and apply to all LIUNA health and welfare funds, require group health plans and insurers to publish a Summary of Benefits and Coverage (SBC) and a glossary of commonly used health insurance and medical terms.

The SBC must be no longer than four double-sided pages and may not contain print smaller than 12-point font. In counties in which ten percent of the population is literate in a non-English language only, the SBC must also be published in that language. Descriptions of benefits must be augmented with common examples consisting of a sample benefit plan for a specified medical condition during a specific period of time based on recognized clinical practice guidelines. New enrollees must automatically receive the SBC and glossary, and it must be updated and re-issued whenever the schedule of benefits changes or the plan is up for renewal. Public comment on the new rules will be accepted through October 17, 2011.

“Workers and their families need clear and understandable information regarding their health coverage,” said Secretary of Labor Hilda L. Solis, speaking for her department, the U.S. Treasury and the Department of Health and Human Services, which jointly issued the new rules. “Today’s proposal is a common-sense step that will help workers quickly and easily compare different coverage options, in order to make more informed decisions.”

Summarized by the International Foundation of Employee Benefit Plans, key features required in the SBC include:

(A) Uniform definitions of standard insurance terms and medical terms so that consumers may compare health coverage and understand the terms of (or exceptions to) their coverage

(B) A description of the coverage, including cost-sharing, for each category of benefits identified in the guidance by the Departments

(C) Exceptions, reductions and limitations of the coverage

(D) Cost-sharing provisions of the coverage, including deductible, co-insurance, and co-payment obligations

(E) Renewability and continuation of coverage provisions

(F) Coverage examples to illustrate common benefits scenarios (including pregnancy and serious or chronic medical conditions) and related cost-sharing based on recognized clinical practice guidelines

(G) With respect to coverage beginning on or after January 1, 2014, a statement about whether the plan or coverage provides “minimum essential coverage” and whether the plan’s share of the total allowed costs of benefits provided under the plan meets applicable requirements

(H) A statement that the SBC is only a summary and that the plan document, policy or certificate of insurance should be consulted to determine the governing contractual provisions of the coverage

(I) Contact information for questions and obtaining a copy of the plan document or the insurance policy, certificate or contract of insurance (such as a telephone number for customer service and an Internet address for obtaining a copy of the plan document or the insurance policy, certificate or contract of insurance)

(J) For plans and carriers that maintain one or more networks of providers, an Internet address (or similar contact information) for obtaining a list of network providers

(K) For plans and carriers that use a formulary in providing prescription drug coverage, an Internet address (or similar contact information) for obtaining information on prescription drug coverage

(L) An Internet address for obtaining the uniform glossary

(M) Premiums (or in the case of a self-funded group health plan, the cost of coverage)

The LHSFNA’s Health Promotion Division continues to monitor developments with regard to the PPACA on its Health Care Reform Updates page.

[Steve Clark]