Final Rules Released Regarding Required Summaries of Coverage

The federal government has just released the finals rules and deadlines that insurance companies and group health care plan sponsors must adhere to in order to remain compliant with the healthcare reform law. The final rules require the dispensing of new compliant plan documents by September 13, 2012; changed from the original date of March 23. Healthcare plan participates are required to receive both a brief summary of benefits and coverage in “plain language, and a glossary of common medical and insurance-related terms.

The summaries must explain primary plan features of each coverage option available to enrollees including all benefits, cost-sharing rules and plan limitations and exceptions. Additionally, the summary must include a comparison tool that provides estimates of how much each plan covers and example estimates of out-of-pocket expenses for maternity care and treatment for type-II diabetes.

The rules also define four circumstances when the summary of benefits and coverage documents must be issued: when potential clients are shopping for plans; at plan renewal time; when a plan changes significantly; and upon the request of a participant. Insurers must provide both the summary and glossary for every eligible benefit. Participants are also required to receive both documents at the beginning of each policy year. When coverage changes during the policy year, participants must be updated no later than 60 days before the coverage changes. Finally, participants are entitled to the documents within one week of a personal request. The change has been instituted in the hopes that both employers and employees will more be able to more easily choose an ideal coverage option.