42 USC 300gg-15 - Development and utilization of uniform explanation of coverage documents and standardized definitions

U.S Code last checked for updates: Nov 25, 2024

§ 300gg–15.

Development and utilization of uniform explanation of coverage documents and standardized definitions

(a)

In general

(b)

Requirements

The standards for the summary of benefits and coverage developed under subsection (a) shall provide for the following:

(1)

Appearance

(2)

Language

(3)

Contents

The standards shall ensure that the summary of benefits and coverage includes—

(A)

uniform definitions of standard insurance terms and medical terms (consistent with subsection (g)) so that consumers may compare health insurance coverage and understand the terms of coverage (or exception to such coverage);

(B)

a description of the coverage, including cost sharing for—

(i)

each of the categories of the essential health benefits described in subparagraphs (A) through (J) of section 18022(b)(1) of this title; and

(ii)

other benefits, as identified by the Secretary;

(C)

the exceptions, reductions, and limitations on coverage;

(D)

the cost-sharing provisions, including deductible, coinsurance, and co-payment obligations;

(E)

the renewability and continuation of coverage provisions;

(F)

a coverage facts label that includes examples to illustrate common benefits scenarios, including pregnancy and serious or chronic medical conditions and related cost sharing, such scenarios to be based on recognized clinical practice guidelines;

(G)

a statement of whether the plan or coverage—

(i)

provides minimum essential coverage (as defined under section 5000A(f) of title 26); and

(ii)

ensures that the plan or coverage share of the total allowed costs of benefits provided under the plan or coverage is not less than 60 percent of such costs;

(H)

a statement that the outline is a summary of the policy or certificate and that the coverage document itself should be consulted to determine the governing contractual provisions; and

(I)

a contact number for the consumer to call with additional questions and an Internet web address where a copy of the actual individual coverage policy or group certificate of coverage can be reviewed and obtained.

(c)

Periodic review and updating

(d)

Requirement to provide

(1)

In general

Not later than 24 months after March 23, 2010, each entity described in paragraph (3) shall provide, prior to any enrollment restriction, a summary of benefits and coverage explanation pursuant to the standards developed by the Secretary under subsection (a) to—

(A)

an applicant at the time of application;

(B)

an enrollee prior to the time of enrollment or reenrollment, as applicable; and

(C)

a policyholder or certificate holder at the time of issuance of the policy or delivery of the certificate.

(2)

Compliance

(3)

Entities in general

An entity described in this paragraph is—

(A)

a health insurance issuer (including a group health plan that is not a self-insured plan) offering health insurance coverage within the United States; or

(B)

in the case of a self-insured group health plan, the plan sponsor or designated administrator of the plan (as such terms are defined in section 1002(16) of title 29).

(4)

Notice of modifications

(e)

Preemption

(f)

Failure to provide

(g)

Development of standard definitions

(1)

In general

(2)

Insurance-related terms

(3)

Medical terms

(July 1, 1944, ch. 373, title XXVII, § 2715, as added and amended Pub. L. 111–148, title I, § 1001(5), title X, § 10101(b), Mar. 23, 2010, 124 Stat. 132, 884.)

cite as: 42 USC 300gg-15