New Rules Will Make it Easier for Consumers to Understand Health Plans

Last week, final rules were issued by the US Departments of Treasury, Labor, and Health and Human Services for the “Summary of Benefits and Coverage (SBC) and Uniform Glossary”. The SBC is a first step in consumer protection, but it also presents opportunities for advocates to get involved.


The Affordable Care Act requires new standards for use by health plans that “accurately describes the benefits and coverage under the applicable plan or coverage” and also calls for the “development of standards for the definition of terms used in health insurance coverage.” The final rule provides additional guidance to health plans that were developed through consultation with national experts and consumer-tested focus groups.

While this may sound complicated and boring, this rule is actually a great step ahead for health care consumers, and in particular, women, who tend to be the primary health care decision makers in families. Confusing language and lengthy, complicated forms make it difficult for consumers to make educated decisions about their plan selection and can lead to poor choices and coverage that doesn’t meet the health care needs of a family or individual.

A total of 12 required content elements are outlined in the final rule, including:
Uniform and standard definitions of medical and health coverage terms
Description of the coverage, including any cost-sharing requirements
Information about any exceptions, reductions, or limitations in their coverage

Plans will also be required to provide notices in a culturally and linguistically appropriate manner, but only when 10% of more of a county’s population is literate in the same non-English language. Currently, this only applies to 255 counties in the US, of which 78 are in Puerto Rico. HHS does plan to make available written translations of the SBC temple, sample language, and glossary in Spanish, Tagalog, Chinese, and Navajo. Advocates and community-based organizations should push plans to make information available in additional languages and continue to play a strong role in helping connect clients with information.

The SBC will also offer coverage examples that will help consumers understand how a plan will cover costs in particular situations, for instance normal delivery of a baby or managing type 2 diabetes.

SBCs will be required starting on the first day of health plans years beginning on or after September 23, 2012. The SBC cannot be longer than four double-sided pages in length and must be printed in 12-point font or larger. Consumers will access the SBC online and hard copies will only be available by request. This is a potential barrier for consumers and advocates should see this as an opportunity to push for broader distribution.

Check out the SBC template and glossary on the Center for Consumer Information and Insurance Oversight’s website and let us know what you think. Will you take the time to read these new forms when they are issued by your health plan? Are there still terms or phrases that are confusing? What can IMCHC and other advocates do to help consumers better understand their options?

This article was originally posted at Birth, Braces and Beyond, the Illinois Maternal and Child Health Coalition's blog. Feel free to share any comments with Kathy Chan, Director of Policy and Advocacy with IMCHC.