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ACA: Basics

Increasing Transparency in Health Care: Summary of Benefits and Coverage A Big Win for Women

For many women – who are most likely to make family decisions regarding health care coverage – final rules for Summary of Benefits and Coverage (SBC) in health plans released by the U.S. Department of Health and Human Services (HHS) last week come with a breath of fresh air. If you have ever had to pick a health insurance plan in the individual market, you probably relied on your previous experience comparing health plans to choose the plan you THINK is the best for you and your family. According to a study by Consumers Union, this is a common occurrence – many people rely on previous experience to make their selection of health coverage plans.

One problem with this is many health plans use different terminology for the same definitions and have different methods for the ways that their deductibles and copays work. This leaves consumers playing a frustrating game of “pin the tail on the donkey.”

Thankfully, starting in September, we can take the blindfold off and start to compare differences in health plans and make meaningful choices for ourselves – and our families – by a more comprehensive and transparent way of comparing our options. The disclosure form, or SBC, will be of required use for all group and nongroup plans.

Key Benefits of the SBC:

  • Standard definitions for medical and coverage terms – increasing uniformity in all plans
  • Maximum four pages in length – making it easy to understand and read
  • Must include cost-sharing information for major benefits, overall cost-sharing provisions (e.g., deductibles) as well as coverage exceptions
  • “Coverage Examples” such as prenatal care and diabetes – creating a full understanding of how the plan will work in practice

Women – who, as stated before, are more likely to be health care decision-makers – will find this provision of health care reform through the Affordable Care Act (ACA) as a more comprehensive approach to comparing and deciding on a plan. A short and more uniform summary and the inclusion of “coverage examples” so that women can see how the plan will work in different scenarios will play a crucial role in comparing coverage options.   Not only does this increase the welfare of Wisconsin women and their families, but – in combination with other provisions of the ACA – can create a better market with real competition based on both cost and quality.



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