Decoding Your Health Plan

According to the Patient Protection and Affordable Care Act, starting on September 23, 2012, your health plan must provide your policy in language you can understand.  Along with that, there’s a new SBC  — Standard Benefits and Coverage — form that all health plans will be using in the U.S. to help you understand what you owe, what they owe, and what isn’t paid at all. 

For example, “urgent care” is described as “care for an illness, injury or condition serious enought that a reasonable person would seek care right away, but not so severe as to rquire emergency room care” which of course requires you to know the definition of “emergency room care.”

According to the U.S. Department of Health and Human Services, before the Affordable Care Act, the marketing materials provided by insurers could make it difficult for consumers to understand what the policies cover and how cost sharing works in order to choose the plan that will work best for your specific health care needs. Newrules require health plans to provide a summary of benefits and coverage, and a list of definitions, designed to make it easier for you to compare your options, and understand exactly what you are buying. The new requirements will also make it easier for employers to compare health insurance options to provide for their employees.

Specifically, under these rules, consumers will have access to two key documents that will be written in plain language, in a standard format, to help you understand and evaluate your choices:

  • A short, easy-to-understand Summary of Benefits and Coverage (or “SBC”). This will include a new, standardized plan comparison tool called “coverage examples,” similar to the Nutrition Facts label required for packaged foods. The coverage examples will illustrate sample medical situations and describe how much coverage the plan would provide in an event such as having a baby (normal delivery) or managing Type 2 diabetes (routine maintenance, well-controlled).
  • A uniform glossary of terms commonly used in health insurance coverage, such as “deductible” and “co-payment.”

It’s a start to better understanding your rights under the health reform law and will bring a common understanding to the insurance marketplace.  If we can learn the language of social media, where “friend” has become a verb and “texting” a household word, perhaps “preauthorization” and “medical necessity” won’t be so scary.


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