Becoming a good health care consumer may get a bit easier for some if new proposed rules from the Departments of Health and Human Services, Labor and the Treasury go into effect next year as planned.

The new regulations under the Affordable Care Act are intended to allow consumers to more easily understand their health coverage and determine the best health insurance options for themselves and their families. The regulators say they also expect employers will benefit by being able to more easily locate the best coverage for their business and their employees.

Under the proposed rules, health insurers and group health plans will be required to provide consumers with what is being called clear, consistent and comparable information about their health plan benefits and coverage.

In announcing the rules Aug. 17, HHS Secretary Kathleen Sebelius said, “Today, many consumers don't have easy access to information in plain English to help them understand the differences in the coverage and benefits provided by different health plans.”

A release issued by HHS said the proposed regulations are intended to accomplish two goals: enable consumers to more easily understand the coverage they already have; and to make apples-to-apples comparisons of available options when purchasing new coverage.

Under the new rules, consumers will be given access to two forms intended to help them understand and evaluate their health insurance choices, including a summary of benefits and coverage, and a uniform glossary of terms commonly used in health insurance coverage, such as “deductible” and “co-pay.”

The proposed rules require all health plans and issuers to provide a summary of benefits and coverage, along with a uniform glossary of terms, to shoppers and enrollees upon request and before they buy coverage.

According to HHS, the summary of benefits and coverage will include a new, standardized health plan or policy comparison tool for consumers known as “coverage examples,” which the department says is much like the nutrition facts label found on packaged foods. Coverage examples would illustrate what proportion of care expenses a health insurance policy or plan would cover for three common benefits scenarios—having a baby, treating breast cancer and managing diabetes. HHS says additional scenarios may be added in the future, but for now, these three examples are expected to help consumers understand and compare their share of the costs of care under a particular policy or plan, and see how valuable the health plan will be at times when they need the coverage.

The new rules and proposed forms were the result of a public process led by the National Association of Insurance Commissioners and a working group composed of stakeholders. These stakeholders include representatives of health insurance-related consumer advocacy organizations, health insurers, health care professionals, patient advocates including those representing individuals with limited English proficiency, and other qualified individuals. The proposed regulations adopt the recommendations submitted by the NAIC after that process, and HHS is now requesting comments on how the forms can be improved.

New rules

America's Health Insurance Plans has already weighed in with a statement on the proposed summary of benefits and coverage rule. The statement issued on the AHIP website the same day the rules were announced pointed out these forms may not be necessary.

According to AHIP, “Health plans increasingly provide user-friendly online tools and clear materials to make sure that consumers understand the benefits and costs of their health insurance policies. The benefits of providing a new summary of coverage document must be balanced against the increased administrative burden and higher costs to consumers and employers. For example, since most large employers customize the benefit packages they provide to their employees, some health plans could be required to create tens of thousands of different versions of this new document—which would add administrative costs without meaningfully helping employees.”

The statement went on to argue the implementation date for the rules should be pushed back since the final regulation has been delayed. This, they say, would give health plans sufficient time to make the operational and administrative changes needed to create these new documents.

In its statement, AHIP promised to submit detailed comments on the proposed rules and indicated that they look forward to working with regulators to mitigate potential unintended consequences of this new requirement.

Instant Insights /

Do rules help consumers or create more paperwork?

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