Feds Release Final Rules on Health Plan Language

The release of the final rule was mandated by Section 2715 of the Affordable Care Act, which required the Secretary of Health and Human Services to "consult with the National Association of Insurance Commissioners" to develop these standards.

The "Summary of Benefits and Coverage" or SBC, required by each plan includes a four-page template summary revealing such specifics as the plan's overall deductible, other deductibles for specific services, annual limits, out-of-pocket limits on expenses and what's not included in the out-of-pocket limit.

Other disclosures include "services this plan doesn't cover," and the specific costs for a typical service, such as a visit with a primary care or specialist provider to treat an injury or illness, in both an in-network or an out-of-network provider, and any limitations or exceptions they may include.

Each plan also will have to provide examples of how it will cover two categories of healthcare services, having a baby with a normal delivery, and routine maintenance of well-controlled Type 2 diabetes.  Each scenario includes breakdowns for specific charges.

For example, the cost of having a normal delivery baby would include disclosure of separate charges for the mother and baby, anesthesia, routine obstetric care, prescriptions, radiology, lab tests and vaccines, and how much the plan pays to provider, and how much the patient pays.

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