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Can somebody who actually understands health insurance benefits take a look at this and comment?

My Eyes Glaze Over:

Public Health Service (PHS) Act section 2715, as added by the Affordable Care Act, directs the Departments to develop standards for use by a group health plan and a health insurance issuer offering group or individual health insurance coverage in compiling and providing a summary of benefits and coverage (SBC) that “accurately describes the benefits and coverage under the applicable plan or coverage.” On February 14, 2012, the Departments published final regulations regarding the SBC.(1) At the same time, the Departments published a notice announcing the availability of templates, instructions, and related materials authorized for implementing the disclosure provisions under PHS Act section 2715 for the first year of applicability (that is, for SBCs and the uniform glossary provided with respect to coverage beginning before January 1, 2014).(2)

The documents authorized for the first year of applicability do not include language for the statement in the SBC (required to be included by PHS Act section 2715(b)(3)(G) and paragraph (a)(2)(i)(G) of the final regulations) regarding whether a plan or coverage provides minimum essential coverage (MEC) and whether the plan's or coverage's share of the total allowed costs of benefits provided under the plan or coverage meets applicable minimum value (MV) requirements. When the documents authorized for the first year of applicability were first released, the Departments stated that updated materials would be issued for later years.(3)

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Rainbow Girl's picture
Submitted by Rainbow Girl on

though I am no insurance expert. (I do have experience dealing with the (in)sufficiency of Summary Plan Description documents in terms of accurately disclosing material terms of a person's health insurance policy, e.g., what is covered, what is not covered, what is your financial exposure under the policy (versus the insurer's), e.g. anything "cost-sharing" related such as copays, deductibles, caps, etc.) SPDs are primarily (I think) a requirement (consumer protection device) in ERISA policy, but may also be required in non-ERISA insurance under individual state laws (though as a general rule insurers own the state legislatures that would pass such protections).

Here's my read. ACA apparently includes an SPD-like requirement in the form of the "SBC," meaning that any insurer issuing an ObamaCare policy (e.g., from the "exchanges," for Loser-Bronze, Silver, Gold, Platinum policies) must provide an SBC to the patient (consumer) disclosing the material terms of coverage and costs.

ACA apparently required HHS (and other "departments" presumably referenced earlier in the regs) to create sample SBC's for use by the insurance companies who will be issuing ACA policies. ACA apparently spelled out a laundry list of disclosures/declarations that ACA insurers have to include in SBCs, including that (1) the policy provides the basic minimum coverage (the supposed "hallmark" of ObamaCare) and (2) the policy meets some (unknown to me) ACA requirement about limits on how much insurers can charge [gouge] ACA policy-holders.

What the posted regulation seems to say is that while HHS (and the other ACA-designated agencies) complied with the ACA directive by creating templates with sample language for the laundry list of ACA-mandated SBC disclosures, no sample language was drafted to make disclosures (1) and (2) above, and that HHS (et al) will be getting around to those at some unspecified future date.

What does this mean? One one level, it seems to mean that the insurance companies issuing ACA-exchange policies will be "on their own" in terms of drafting language in their SBCs making disclosures/affirmations (1) and (2) to policy-holders. On the other hand, there could be buried in the gobbledygook some escape hatch for insurers where -- because HHS hasn't issued sample language for (1) and (2) -- ACA insurers are not required to swear that they are complying with (1) and (2).

Either way this seems odd, because (1) and (2) strike me as the equivalent of the Sarbanes-Oxley declarations required of CEOs with respect to the integrity of a corporations' financial state and health. In the case of ACA, (1) and (2) would be the only mechanism to hold ACA insurers to the supposedly core "virtues" of ACA (minimum level of benefits and limits on gouging policy-holders) [yes, I know -- ha ha.]

It would be child's play to draft these two sample disclosures: "This policy meets MAC." "This policy meets MV requirements."

It is an understatement to see this as a baffling omission by HHS.

I look forward to hearing from someone who knows more about this subject.

Thanks for posting, Lambert.

Submitted by lambert on

You write:

What the posted regulation seems to say is that while HHS (and the other ACA-designated agencies) complied with the ACA directive by creating templates with sample language for the laundry list of ACA-mandated SBC disclosures, no sample language was drafted to make disclosures (1) and (2) above, and that HHS (et al) will be getting around to those at some unspecified future date.

Wny isn't the template the sample language? This is horrible. What am I missing?

Rainbow Girl's picture
Submitted by Rainbow Girl on

Not sure I understand? (And MEGO as well, big time.)

I was using "templates" and "sample language" interchangeably, assuming that what's at issue is (basically) creating templates with sample language.
What I am deducing the excerpted regulation says -- as a mere lay person -- is that HHS failed/neglected to/forgot/did not draft any sample language for disclosures (1) and (2) in any of the templates (or whatever documents with suggested language for the insurers) they did draft. What the reg seems to say is that HHS did, however, provide sample language (in or outside templates) regarding whatever the other ACA mandated SBC disclosures are (which are not listed or referenced in the reg and one would have to hop around to the cited provision to find.)

Rainbow Girl's picture
Submitted by Rainbow Girl on

That:
(1) the policy provides the basic minimum coverage (the supposed "hallmark" of ObamaCare) and

(2) the policy meets some (unknown to me) ACA requirement about limits on how much insurers can charge [gouge] ACA policy-holders.

Rainbow Girl's picture
Submitted by Rainbow Girl on

It's not that the templates do not include *any* sample language, just sample language relating to two of the required disclosures/statements. The HHS statement in your post implies that there is a slew of other ACA required SBC disclosures for which HHS (et al) *have* created templates/sample language, but they somehow didn't do this for (1) and (2), which I try to explain better below.

As per the excerpted passage in your post:

PHS Act section 2715(b)(3)(G) and paragraph (a)(2)(i)(G) of the final regulations apparently require ACA policies to include an SBC that has these two disclosures:

(1) that "a plan or coverage provides minimum essential coverage (MEC), and

(2) that "the plan's or coverage's share of the total allowed costs of benefits provided under the plan or coverage meets applicable minimum value (MV) requirements."

So we could call (1) the "MEC affirmation" and (2) the "MV affirmation." I don't see these as "disclosures of terms" so much as actionable statements by the insurers that the policy they issue (1) provides the vaunted "minimum coverage" requirements of ACA and (2) doesn't charge policy-holders more out of pocket than what ACA says is allowable (which I have *no* idea what that is and had *no* idea such a "standard" even existed.)

Hope this is a little clearer (relatively speaking, since ACA and clarity don't coexist on planet Earth).

Submitted by lambert on

It would seem they would mandate the declaration that the one of the central claims of ObamaCare is being met.

Rainbow Girl's picture
Submitted by Rainbow Girl on

the mimimum coverage and the limits on "cost-sharing" (cost-shifting).*

I don't care if the policies swear on the Constitution that they comply with everything in ObamaCare since viewing ObamaCare in the most virtuous light still yields an inherently defective product that leaves the mark without health care and drastically impoverished.