Under final regulations issued February 9, group health plans must issue a summary of benefits and coverage and a uniform glossary. The final rule implements a Patient Protection and Affordable Care Act (PPACA) requirement of group health plans to provide its enrollees and potential enrollees with certain disclosures to help them better understand their health coverage, as well as to learn about additional coverage options. The final regulations were the combined effort of the Internal Revenue Service, the Employee Benefits Security Administration, and the Centers for Medicare & Medicaid Services, the three agencies responsible for implementing healthcare reform legislation under PPACA.
The final regulations also set forth the standards for who provides the summary of benefits and coverage, to whom, and when. For insured plans, the insurer is responsible for providing the summary, while the plan administrator has such responsibility for self-insured plans. The summary must be provided in several different circumstances, such as during open enrollment, when an individual first applies for coverage, upon a renewal, or upon request.
Each summary must contain certain items, including uniform standard definitions of medical and health coverage terms; a description of the coverage provided; and information regarding any exceptions, reductions or limitations under the coverage. The summary must also include coverage examples and illustrations of plan benefits. The regulations also contain rules related to the appearance of the summary of benefits and coverage, including font size and length restrictions.
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