For those with special healthcare needs, finding out what was covered in qualified health plans has been a challenge, but a new regulation put in place this past summer in time for Open Enrollment Year 3 (OE3) has provided access to much-needed valuable information. This will be especially helpful for individuals needing coverage in areas such as durable medical equipment (DME), rehabilitation and habilitation benefits. Individuals who use DME many times had difficulty learning what was covered in a plan prior to enrollment, including whether repair and replacement were covered as well as the initial purchase of the equipment. DME along with rehabilitation and habilitation benefits are not addressed on the typical Summary of Benefits and Coverage (SBC) and are usually only spelled out in the plan documents. These plan documents were not always available to consumers who were shopping for coverage and considering which plan was the best fit for them. Some states require health insurance carriers to provide the plan documents to the consumer prior to enrollment if the consumer requests a copy. However, there are many states where that requirement is not in place and the consumer can only acquire the plan documents and review them thoroughly once they are enrolled.
While “medical devices” were one of the 10 Essential Health Benefits in the Affordable Care Act, it was never a defined term and therefore it was left up to the states and individual insurance plans to determine what was covered in this area. Therefore, not having this information prior to enrollment became very problematic for individuals who had more specialized medical needs such as DME, rehabilitation and habilitation benefits. These consumers were required to buy insurance not knowing if the plan they were purchasing was going to even cover their specific medical needs.
This past summer, HHS issued new rules which govern the SBC for every plan issued through the Marketplace. The new rules now require that every SBC have indicated where additional information can be accessed on the carrier’s website concerning what is covered on the plan. Specifically, the SBC must have a link to the carrier’s website to the location where the plan documents can be accessed.
The NDNRC is pleased to report that we tested out this feature on five different plans with five different insurance companies that were offered on the Federally Facilitated Marketplace in Pennsylvania. In every instance, we were able to locate information as to the coverage of DME, rehabilitation and habilitation benefits. It should be noted that the coverage documents are rather lengthy and on a few occasions it took quite a bit of reading to find the information, but the information was available. We applaud HHS for making this needed change so that consumers can have the information they need in order to make the most transparent decision regarding their healthcare coverage.
For additional information on the Summary of Benefits and Coverage, the Evidence of Coverage Documents or DME and rehabilitation and habilitation benefits, check out the following fact sheets: