Health Insurance

Starting September 23, 2012 or soon after, health insurance issuers and group health plans will be required to provide you with an easy-to-understand summary about a health plan’s benefits and coverage. The new regulation is designed to help you better understand and evaluate your health insurance choices.

The new forms include:

• A short, plain language Summary of Benefits and Coverage, or SBC
• A uniform glossary of terms commonly used in health insurance coverage, such as "deductible" and "copayment"

All insurance companies and group health plans will use the same standard SBC form to help you compare health plans. The SBC form also includes details, called “coverage examples,” which are comparison tools that allow you to see what the plan would generally cover in two common medical situations. You will have the right to receive the SBC when shopping for or enrolling in coverage or if you request a copy from your issuer or group health plan.  You may also request a copy of the glossary of terms from your health insurance company or group health plan.

 What This Means for You

It’s not easy for consumers to know what they are buying when shopping for insurance. The new rules are a joint effort among the Department of Health and Human Services, the Department of Labor, and the Department of the Treasury. The SBC is designed after the Nutrition Facts label required for packaged foods which helps you make healthy and informed decisions about your diet. The SBC’s standardized and easy to understand information about health plan benefits and coverage allows you to more easily make “apples to apples” comparisions among your insurance options. The measure brings more openness to the insurance marketplace for the more than 180 million Americans with private health coverage. 

Some Important Details

• This provision applies to all health plans, whether you get coverage through your employer or purchase it yourself, beginning September 23, 2012.
• All health plans must provide an SBC to shoppers and enrollees at important points in the enrollment process, such as upon application and at renewal.
• The coverage examples give a general sense of how a plan would cover the normal delivery of a baby, and services to help a person control type 2 diabetes.
• If you don’t speak English, you may be entitled to receive the SBC and uniform glossary in your native language upon request.

Many states offer help to consumers with health insurance problems. The Affordable Care Act improves these services with grants that help states start or strengthen Consumer Assistance Programs (CAPs). The states and territories that applied for these grants have received funds provide residents direct help with problems or questions about health coverage.

Get Help with a Problem or Question

Whether or not your state has a Consumer Assistance Program, you have rights under the health care law, including the right to appeal decisions made by your health insurance provider.

If your state does not have a Consumer Assistance Program, some state and federal government offices may still be able to help you determine your rights and solve problems. Use the map to find resources and contact information that may provide this help. Get phone numbers, email addresses, and other contact information.

What This Means for You

Before the health care law, you often had to fend for yourself when trying to find affordable health insurance or resolve problems with a health plan. Even in states with programs to help consumers, those programs often have been overburdened and underfunded.

Now, federal grants are helping states and territories build Consumer Assistance Programs that offer more hands-on assistance to more people. These programs can help you:

•   File complaints and appeals.
•   Enroll in health coverage.
•   Get educated about your rights and responsibilities.

These programs also collect data on the types of problems consumers are having. They will file reports with the Secretary of the U.S. Department of Health and Human Services to identify trouble spots that may need further oversight.

Some Important Details

Evidence shows that hands-on consumer assistance programs resolve complaints and appeals effectively:

•   In 2009, one state program recovered more than $1.4 million on behalf of consumers.
•   Another state program recouped $20 million.

In addition to helping consumers with immediate problems, Consumer Assistance Programs will help consumers understand other health care reforms designed to make the health insurance marketplace more competitive and patient-centered in 2014 and beyond.

 

The Affordable Care Act ensures your right to appeal health insurance plan decisions--to ask that your plan reconsider its decision to deny payment for a service or treatment. New rules that apply to health plans created after March 23, 2010 spell out how your plan must handle your appeal (usually called an “internal appeal”). If your plan still denies payment after considering your appeal, the law permits you to have an independent review organization decide whether to uphold or overturn the plan’s decision. This final check is often referred to as an “external review.”

Your state may have a health care Consumer Assistance Program that can help you file an appeal or request a review.

What This Means for You

• When an insurance plan denies payment for a treatment or service, you can request an appeal. When your plan receives your request it is required to review its own decision. For plan years or policy years beginning on or after July 1, 2011, when your plan denies a claim, it is required to notify you of:
  • The reason your claim was denied.
  • Your right to file an internal appeal.
  • Your right to request an external review if your internal appeal was unsuccessful.
  • The availability of a Consumer Assistance Program (when your state has one).
    
• If you don’t speak English, you may be entitled to receive appeals information in your native language upon request. This right applies to plan years or policy years beginning on or after January 1, 2012.

• When you request an internal appeal, your plan must give you its decision within:
  • 72 hours after receiving your request when you’re appealing the denial of a claim for urgent care. (If your appeal concerns urgent care, you may be able to have the internal appeal and external review take place at the same time.)
  • 30 days for denials of non-urgent care you have not yet received.
  • 60 days for denials of services you have already received
  If after internal appeal the plan still denies your request for payment or services, you can ask for an independent external review. For plan years or policy years that begin on or after July 1, 2011, your plan must include information on your denial notice about how to request this review. If your state has a Consumer Assistance Program, that program can help you with this request.

• If the external reviewer overturns your insurer’s denial, your insurer must give you the payments or services you requested in your claim.

Some Important Details

• The parts of the Affordable Care Act that concern internal appeals and external reviews apply only to health plans or policies that were created or purchased after March 23, 2010. Plans created on or before March 23, 2010, may be “grandfathered health plans.” The appeals and review rights do not apply to them.
• Your internal appeals rights in the health care reform law take effect when your plan starts a new plan year or policy year on or after September 23, 2010.
• Your external review rights will take effect by January 1, 2012. Some states already have an external review process that meets the new rules.
• How much these new rules will change your current appeal rights depends on the state you live in and the type of plan you have. Some group plans may require more than one level of internal appeal before you’re allowed to submit a request for an external review. However, all levels of the internal appeals process must be completed within the timelines above.