Mandated summary of benefits long overdue

Summary of Benefits and Coverage forms let shoppers see what's covered – and what's not – before they buy

  • By
  • healthinsurance.org contributor
  • August 18, 2011

EDITOR’S NOTE (10-31-13):  For additional current information about Summary of Benefits and Coverage forms, read this FAQ from the Department of Labor.

Premiums, copays and deductibles, oh my! I’ve been writing about health insurance for nearly 20 years and I still get confused trying to figure out the bottom line on my health coverage.

summary-of-benefits-and-coverage

Starting in 2012, all health plans and plan issuers must provide a Summary of Benefits and Coverage to consumers before they buy a health insurance plan.

In 2012, consumers are supposed to get some new, improved health plan descriptions from insurance companies, thanks to health reform. The proposed six-page forms came out Wednesday for public comment.

My impression? The new forms are an improvement over the lengthy, jargon-filled, legalistic communications that consumers usually face when trying to buy health insurance or understand what they or their employer have already signed up for. There are simple questions and answers about what’s covered and what’s not. They’ve also added a few handy examples of what a given health plan would cover for specific situations: having a baby, treating breast cancer and managing diabetes.

At the same time, health insurance in America is just damn complicated, as these forms make clear – even as they attempt to boil it all down. The summary of benefits lists the premium, the overall deductible, other deductibles, out-of-pocket limits, annual limits, and anything the plan doesn’t cover. Consumers will still need to read carefully and ask questions to truly understand what they’re getting, and what they’re not.

There are also caveats wherever you go. For instance, on the page that offers specific examples, there is language that reminds you: “Don’t use these examples to estimate your actual costs under this plan.” OK, so why do we have the examples again?

Already the insurance industry is carping about the potential complexity of having to write “tens of thousands” of different versions of this form for all the health plans different employers negotiate, according to an article in the Wall Street Journal. But the federal regulators will likely fix that, the Journal adds.

Consumer organizations are happy to see the simplified form. Ron Pollack, executive director of Families USA, calls it a “triumph of common sense,” and adds that “companies who respect their customers and want to encourage competition in the health insurance marketplace should also applaud the rules – clearly describing a product you are offering for sale should not be perceived as a heavy lift.” Indeed.

The public (and, believe me, every insurance company lobbyist in existence) gets a chance to comment on the proposed forms before the government agencies make them final, and they start getting used in 2012. Let’s hope they keep improving on what they’ve got so far, keeping the average person in mind.


Jan Greene is a health care writer who has been reporting about the health care system for nearly 20 years. Her work has appeared in the Los Angeles TimesHealth magazine, OnHealth.com and a variety of trade publications for doctors and health care organizations. Check out Jan’s previous articles for the Health Insurance Resource Center about the self-employed health insurance deduction, preventive services for women, free preventive services for seniors in Medicare and health insurance for elderly new immigrants.

Comments