It’s hard to imagine ever having to read more than the basic information that you receive about your health insurance policy, but it’s important to know that many situations arise when not knowing what your plan says can leave you with less or different health insurance coverage than you anticipated. In addition to providing the only source of information upon which you can make a completely informed decision, one of the key reasons for knowing what your rights are when it comes to the content of your insurance plan will frequently revolve around your right to appeal your insurance company’s decisions.
Start with the framework. While an insurance policy provides you with rights, it also creates rights for your insurance company concerning how they can avoid making payments or in more benign terms, explaining exactly what they do or don’t cover.
The ACA acknowledges the difficulty in getting information and understanding insurance coverage but does not go very far in terms of helping policy holders because of two factors, first that insurers want to be held to finite liability so that their documents are crafted to clearly indicate just how far coverage goes and in accounting for every detail the word count goes up precipitously. The second reason that the ACA provides limited additional assistance for individuals is a result of the length of the document which means that most of us will not read through the entire policy unless we need to.
What the ACA does do in section 2715, “Development and Utilization of Uniform Explanation of Coverage Documents and Standardized Definitions,” is in section (a) provide for SBCs, summaries of benefits and coverage to accurately describe the plan. This format is already commonly available in terms of a Summary of Benefits and Coverage documents prepared by insurers as online resources for insureds.
Note that section 2715 (b)(Requirements)(3)(Contents)(H) requires that SBCs include text warning and informing consumers that the coverage document itself must be consulted to determine the governing contractual provisions. This is important because although most of us rely on summaries of benefits, they are NEVER complete. Only the plan itself can be considered a binding document.
The Summary of Benefits and Coverage document must have contact information in terms of a phone number that you can use to get a copy of the actual policy or certificate that represents your policy. It should be noted that after your request, the plan has seven days in which to send you documents (including the option to send the material out on the seventh day which means you’ll get it later) if you request a hard copy BUT under section 2715 (b) (3) (I), there must be a web address that you can use to access the complete policy online. This is important in order to be able to access information in situations where time is of the essence.
Other helpful but not decisively valuable changes that we can expect include efforts at standardizing health insurance language to make it easier to compare the coverage provided by different plans and to better understand the definitions of various terms. While standardization is likely to be helpful, it does not solve the problem of the sheer complexity of health insurance documents. You will likely also need to consult with other resources to better understand what is or is not covered in the event you have questions about your healthcare coverage.
